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Magnitude of Potentially Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting
Venous thromboembolism (VTE) affects more than 1 million patients and costs the US healthcare system more than $1.5 billion annually.1 Inherited and acquired thrombophilias have been perceived as important risk factors in assessing the risk of VTE recurrence and guiding the duration of anticoagulation.
Thrombophilias increase the risk of a first thrombotic event, but existing data have failed to demonstrate the usefulness of routine thrombophilia screening on subsequent management.2,3 Moreover, thrombophilia testing ordered in the context of an inpatient hospitalization is limited by confounding factors, especially during an acute thrombotic event or in the setting of concurrent anticoagulation.4
Recognizing the costliness of routine thrombophilia testing, The American Society of Hematology introduced its Choosing Wisely campaign in 2013 in an effort to reduce test ordering in the setting of provoked VTEs with a major transient risk factor.5 In order to define current practice behavior at our institution, we conducted a retrospective study to determine the magnitude and financial impact of potentially inappropriate thrombophilia testing in the inpatient setting.
METHODS
We performed a retrospective analysis of thrombophilia testing across all inpatient services at a large, quaternary-care academic institution over a 2-year period. Electronic medical record data containing all thrombophilia tests ordered on inpatients from June 2013 to June 2015 were obtained. This study was exempt from institutional review board approval.
Inclusion criteria included any inpatient for which thrombophilia testing occurred. Patients were excluded if testing was ordered in the absence of VTE or arterial thrombosis or if it was ordered as part of a work-up for another medical condition (see Supplementary Material).
Thrombophilia testing was defined as any of the following: inherited thrombophilias (Factor V Leiden or prothrombin 20210 gene mutations, antithrombin, or protein C or S activity levels) or acquired thrombophilias (lupus anticoagulant [Testing refers to the activated partial thromboplastin time lupus assay.], beta-2 glycoprotein 1 immunoglobulins M and G, anticardiolipin immunoglobulins M and G, dilute Russell’s viper venom time, or JAK2 V617F mutations).
Extracted data included patient age, sex, type of thrombophilia test ordered, ordering primary service, admission diagnosis, and objective confirmation of thrombotic events. The indication for test ordering was determined via medical record review of the patient’s corresponding hospitalization. Each test was evaluated in the context of the patient’s presenting history, hospital course, active medications, accompanying laboratory and radiographic studies, and consultant recommendations to arrive at a conclusion regarding both the test’s reason for ordering and whether its indication was “inappropriate,” “appropriate,” or “equivocal.” Cost data were obtained through the Centers for Medicare & Medicaid Services (CMS) Clinical Laboratory Fee Schedule for 2016 (see Supplementary Material).6
The criteria for defining test appropriateness were formulated by utilizing a combination of major society guidelines and literature review.5,7-10 The criteria placed emphasis upon the ordered tests’ clinical relevance and reliability and were subsequently reviewed by a senior hematologist with specific expertise in thrombosis (see Supplementary Material).
Two internal medicine resident physician data reviewers independently evaluated the ordered tests. To ensure consistency between reviewers, a sample of identical test orders was compared for concordance, and a Cohen’s kappa coefficient was calculated. For purposes of analysis, equivocal orders were included under the appropriate category, as this study focused on the quantification of potentially inappropriate ordering practices. Pearson chi-square testing was performed in order to compare ordering practices between services using Stata.11
RESULTS
In total, we reviewed 2179 individual tests, of which 362 (16.6%) were excluded. The remaining 1817 tests involved 299 patients across 26 primary specialties. Fifty-two (2.9% of orders) were ultimately deemed equivocal. The Table illustrates the overall proportion and cost of inappropriate test ordering as well as testing characteristics of the most commonly encountered thrombotic diagnoses. The Figure illustrates the proportion of potentially inappropriate test ordering with its associated cost by test type.
Orders for Factor V Leiden, prothrombin 20210, and protein C and S activity levels were most commonly deemed inappropriate due to the test results’ failure to alter clinical management (97.3%, 99.2%, 99.4% of their inappropriate orders, respectively). Antithrombin testing (59.4%) was deemed inappropriate most commonly in the setting of acute thrombosis. The lupus anticoagulant (82.8%) was inappropriately ordered most frequently in the setting of concurrent anticoagulation.
Ordering practices were then compared between nonteaching and teaching inpatient general medicine services. We observed a higher proportion of inappropriate tests ordered by the nonteaching services as compared to the teaching services (120 of 173 orders [69.4%] versus 125 of 320 [39.1%], respectively; P < 0.001).
The interreviewer kappa coefficient was 0.82 (P < 0.0001).
DISCUSSION
This retrospective analysis represents one of the largest examinations of inpatient thrombophilia testing practices to date. Our results illustrate the high prevalence and significant financial impact of potentially inappropriate thrombophilia testing conducted in the inpatient setting. The data confirm that, per our defined criteria, more than 90% of inherited thrombophilia testing was potentially inappropriate while the majority of acquired thrombophilia testing was appropriate, with the exception of the lupus anticoagulant.
Even when appropriately ordered, studies suggest that positive thrombophilia screening results fail to impact outcomes in most patients with VTE. In an effort to evaluate positive results’ potential to provide a basis from which to extend the duration of anticoagulation, and therefore reduce the risk of a recurrent VTE, a case-control analysis was performed on a series of patients with a first-VTE event (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis [MEGA] study).3 In examining the odds ratio (OR) for recurrence between patients who did or did not undergo testing for Factor V Leiden, antithrombin, or protein C or S activity, the data failed to show an impact of testing on the risk of VTE recurrence (OR 1.2; confidence interval, 0.8-1.8). In fact, decision making has increasingly relied on patients’ clinical characteristics rather than thrombophilia test results to guide anticoagulation duration after incident VTEs. A 2017 study illustrated that when using a clinical decision rule (Clinical Decision Rule Validation Study to Predict Low Recurrent Risk in Patients With Unprovoked Venous Thromboembolism [REVERSE criteria]) in patients with a first, unprovoked VTE, routine thrombophilia screening added little to determining the need for prolonged anticoagulation.12 These findings support the limited clinical utility of current test ordering practices for the prediction and management of recurrent venous thrombosis.
Regarding the acquired thrombophilias, antiphospholipid antibody testing was predominantly ordered in a justified manner, which is consistent with the notion that test results could affect clinical management, such as anticoagulation duration or choice of anticoagulant.13 However, the validity of lupus anticoagulant testing was limited by the frequency of patients on concurrent anticoagulation.
Financially, the cumulative cost associated with inappropriate ordering was substantial, regardless of the thrombotic event in question. Moreover, our calculated costs are derived from CMS reimbursement rates and likely underestimate the true financial impact of errant testing given that commercial laboratories frequently charge at rates several-fold higher. On a national scale, prior analyses have suggested that the annual cost of thrombophilia testing, based on typical commercial rates, ranges from $300 million to $672 million.14
Researchers in prior studies have similarly examined the frequency of inappropriate thrombophilia testing and methods to reduce it. Researchers in a 2014 study demonstrated initially high rates of inappropriate inherited thrombophilia testing, and then showed marked reductions in testing and cost savings across multiple specialties following the introduction of a flowchart on a preprinted order form.15 Our findings provide motivation to perform similar endeavors.
The proportional difference of inappropriate ordering observed between nonteaching- and teaching-medicine services indicates a potential role for educational interventions. We recently completed a series of lectures on high-value thrombophilia ordering for residents and are actively analyzing its impact on subsequent ordering practices. We are also piloting an electronic best practice advisory for thrombophilia test ordering. Though the advisory may be overridden, providers are asked to provide justification for doing so on a voluntary basis. We plan to evaluate its effect on our findings reported in this study.
We acknowledge that our exclusion criteria resulted in the omission of testing across a spectrum of nonthrombotic clinical conditions, raising the question of selection bias. Because there are no established guidelines to determine the appropriateness of testing in these scenarios, we chose to limit the analysis of errant ordering to the context of thrombotic events. Other limitations of this study include the analysis of equivocal orders as appropriate. However, because equivocal ordering represented less than 3% of all analyzed orders, including these as inappropriate would not have significantly altered our findings.
CONCLUSIONS
A review of thrombophilia testing practices at our institution demonstrated that inappropriate testing in the inpatient setting is a frequent phenomenon associated with a significant financial impact. This effect was more pronounced in inherited versus acquired thrombophilia testing. Testing was frequently confounded and often failed to impact patients’ short- or long-term clinical management, regardless of the result.
These findings serve as a strong impetus to reduce the burden of routine thrombophilia testing during hospital admissions. Our data demonstrate a need for institution-wide changes such as implementing best practice advisories, introducing ordering restrictions, and conducting educational interventions in order to reduce unnecessary expenditures and improve patient care.
Disclosure
The authors have nothing to disclose.
1. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29(8):943-953. PubMed
2. Cohn DM, Vansenne F, de Borgie CA, Middeldorp S. Thrombophilia testing for prevention of recurrent venous thromboembolism. Cochrane Database Syst Rev. 2012;12:Cd007069. PubMed
3. Coppens M, Reijnders JH, Middeldorp S, Doggen CJ, Rosendaal FR. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost. 2008;6(9):1474-1477. PubMed
4. Somma J, Sussman, II, Rand JH. An evaluation of thrombophilia screening in an urban tertiary care medical center: A “real world” experience. Am J Clin Pathol. 2006;126(1):120-127. PubMed
5. Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood. 2013;122(24):3879-3883. PubMed
6. Centers for Medicare & Medicaid Services: Clinical Laboratory Fee Schedule Files. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html. Accessed October 2016
7. Stevens SM, Woller SC, Bauer KA, et al. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis. 2016;41(1):154-164. PubMed
8. Moll S. Thrombophilia: clinical-practical aspects. J Thromb Thrombolysis. 2015;39(3):367-378. PubMed
9. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for vte disease: Chest guideline and expert panel report. Chest. 2016;149(2):315-352. PubMed
10. Baglin T, Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010;149(2):209-220. PubMed
11. Stata Statistical Software [computer program]. Version Release 14. College Station, TX: StataCorp LP; 2015.
12. Garcia-Horton A, Kovacs MJ, Abdulrehman J, Taylor JE, Sharma S, Lazo-Langner A. Impact of thrombophilia screening on venous thromboembolism management practices. Thromb Res.149:76-80. PubMed
13. Schulman S, Svenungsson E, Granqvist S. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Duration of Anticoagulation Study Group. Am J Med. 1998;104(4):332-338. PubMed
14. Petrilli CM, Heidemann L, Mack M, Durance P, Chopra V. Inpatient inherited thrombophilia testing. J Hosp Med. 2016;11(11):801-804. PubMed
15. Smith TW, Pi D, Hudoba M, Lee AY. Reducing inpatient heritable thrombophilia testing using a clinical decision-making tool. J Clin Pathol. 2014;67(4):345-349. PubMed
Venous thromboembolism (VTE) affects more than 1 million patients and costs the US healthcare system more than $1.5 billion annually.1 Inherited and acquired thrombophilias have been perceived as important risk factors in assessing the risk of VTE recurrence and guiding the duration of anticoagulation.
Thrombophilias increase the risk of a first thrombotic event, but existing data have failed to demonstrate the usefulness of routine thrombophilia screening on subsequent management.2,3 Moreover, thrombophilia testing ordered in the context of an inpatient hospitalization is limited by confounding factors, especially during an acute thrombotic event or in the setting of concurrent anticoagulation.4
Recognizing the costliness of routine thrombophilia testing, The American Society of Hematology introduced its Choosing Wisely campaign in 2013 in an effort to reduce test ordering in the setting of provoked VTEs with a major transient risk factor.5 In order to define current practice behavior at our institution, we conducted a retrospective study to determine the magnitude and financial impact of potentially inappropriate thrombophilia testing in the inpatient setting.
METHODS
We performed a retrospective analysis of thrombophilia testing across all inpatient services at a large, quaternary-care academic institution over a 2-year period. Electronic medical record data containing all thrombophilia tests ordered on inpatients from June 2013 to June 2015 were obtained. This study was exempt from institutional review board approval.
Inclusion criteria included any inpatient for which thrombophilia testing occurred. Patients were excluded if testing was ordered in the absence of VTE or arterial thrombosis or if it was ordered as part of a work-up for another medical condition (see Supplementary Material).
Thrombophilia testing was defined as any of the following: inherited thrombophilias (Factor V Leiden or prothrombin 20210 gene mutations, antithrombin, or protein C or S activity levels) or acquired thrombophilias (lupus anticoagulant [Testing refers to the activated partial thromboplastin time lupus assay.], beta-2 glycoprotein 1 immunoglobulins M and G, anticardiolipin immunoglobulins M and G, dilute Russell’s viper venom time, or JAK2 V617F mutations).
Extracted data included patient age, sex, type of thrombophilia test ordered, ordering primary service, admission diagnosis, and objective confirmation of thrombotic events. The indication for test ordering was determined via medical record review of the patient’s corresponding hospitalization. Each test was evaluated in the context of the patient’s presenting history, hospital course, active medications, accompanying laboratory and radiographic studies, and consultant recommendations to arrive at a conclusion regarding both the test’s reason for ordering and whether its indication was “inappropriate,” “appropriate,” or “equivocal.” Cost data were obtained through the Centers for Medicare & Medicaid Services (CMS) Clinical Laboratory Fee Schedule for 2016 (see Supplementary Material).6
The criteria for defining test appropriateness were formulated by utilizing a combination of major society guidelines and literature review.5,7-10 The criteria placed emphasis upon the ordered tests’ clinical relevance and reliability and were subsequently reviewed by a senior hematologist with specific expertise in thrombosis (see Supplementary Material).
Two internal medicine resident physician data reviewers independently evaluated the ordered tests. To ensure consistency between reviewers, a sample of identical test orders was compared for concordance, and a Cohen’s kappa coefficient was calculated. For purposes of analysis, equivocal orders were included under the appropriate category, as this study focused on the quantification of potentially inappropriate ordering practices. Pearson chi-square testing was performed in order to compare ordering practices between services using Stata.11
RESULTS
In total, we reviewed 2179 individual tests, of which 362 (16.6%) were excluded. The remaining 1817 tests involved 299 patients across 26 primary specialties. Fifty-two (2.9% of orders) were ultimately deemed equivocal. The Table illustrates the overall proportion and cost of inappropriate test ordering as well as testing characteristics of the most commonly encountered thrombotic diagnoses. The Figure illustrates the proportion of potentially inappropriate test ordering with its associated cost by test type.
Orders for Factor V Leiden, prothrombin 20210, and protein C and S activity levels were most commonly deemed inappropriate due to the test results’ failure to alter clinical management (97.3%, 99.2%, 99.4% of their inappropriate orders, respectively). Antithrombin testing (59.4%) was deemed inappropriate most commonly in the setting of acute thrombosis. The lupus anticoagulant (82.8%) was inappropriately ordered most frequently in the setting of concurrent anticoagulation.
Ordering practices were then compared between nonteaching and teaching inpatient general medicine services. We observed a higher proportion of inappropriate tests ordered by the nonteaching services as compared to the teaching services (120 of 173 orders [69.4%] versus 125 of 320 [39.1%], respectively; P < 0.001).
The interreviewer kappa coefficient was 0.82 (P < 0.0001).
DISCUSSION
This retrospective analysis represents one of the largest examinations of inpatient thrombophilia testing practices to date. Our results illustrate the high prevalence and significant financial impact of potentially inappropriate thrombophilia testing conducted in the inpatient setting. The data confirm that, per our defined criteria, more than 90% of inherited thrombophilia testing was potentially inappropriate while the majority of acquired thrombophilia testing was appropriate, with the exception of the lupus anticoagulant.
Even when appropriately ordered, studies suggest that positive thrombophilia screening results fail to impact outcomes in most patients with VTE. In an effort to evaluate positive results’ potential to provide a basis from which to extend the duration of anticoagulation, and therefore reduce the risk of a recurrent VTE, a case-control analysis was performed on a series of patients with a first-VTE event (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis [MEGA] study).3 In examining the odds ratio (OR) for recurrence between patients who did or did not undergo testing for Factor V Leiden, antithrombin, or protein C or S activity, the data failed to show an impact of testing on the risk of VTE recurrence (OR 1.2; confidence interval, 0.8-1.8). In fact, decision making has increasingly relied on patients’ clinical characteristics rather than thrombophilia test results to guide anticoagulation duration after incident VTEs. A 2017 study illustrated that when using a clinical decision rule (Clinical Decision Rule Validation Study to Predict Low Recurrent Risk in Patients With Unprovoked Venous Thromboembolism [REVERSE criteria]) in patients with a first, unprovoked VTE, routine thrombophilia screening added little to determining the need for prolonged anticoagulation.12 These findings support the limited clinical utility of current test ordering practices for the prediction and management of recurrent venous thrombosis.
Regarding the acquired thrombophilias, antiphospholipid antibody testing was predominantly ordered in a justified manner, which is consistent with the notion that test results could affect clinical management, such as anticoagulation duration or choice of anticoagulant.13 However, the validity of lupus anticoagulant testing was limited by the frequency of patients on concurrent anticoagulation.
Financially, the cumulative cost associated with inappropriate ordering was substantial, regardless of the thrombotic event in question. Moreover, our calculated costs are derived from CMS reimbursement rates and likely underestimate the true financial impact of errant testing given that commercial laboratories frequently charge at rates several-fold higher. On a national scale, prior analyses have suggested that the annual cost of thrombophilia testing, based on typical commercial rates, ranges from $300 million to $672 million.14
Researchers in prior studies have similarly examined the frequency of inappropriate thrombophilia testing and methods to reduce it. Researchers in a 2014 study demonstrated initially high rates of inappropriate inherited thrombophilia testing, and then showed marked reductions in testing and cost savings across multiple specialties following the introduction of a flowchart on a preprinted order form.15 Our findings provide motivation to perform similar endeavors.
The proportional difference of inappropriate ordering observed between nonteaching- and teaching-medicine services indicates a potential role for educational interventions. We recently completed a series of lectures on high-value thrombophilia ordering for residents and are actively analyzing its impact on subsequent ordering practices. We are also piloting an electronic best practice advisory for thrombophilia test ordering. Though the advisory may be overridden, providers are asked to provide justification for doing so on a voluntary basis. We plan to evaluate its effect on our findings reported in this study.
We acknowledge that our exclusion criteria resulted in the omission of testing across a spectrum of nonthrombotic clinical conditions, raising the question of selection bias. Because there are no established guidelines to determine the appropriateness of testing in these scenarios, we chose to limit the analysis of errant ordering to the context of thrombotic events. Other limitations of this study include the analysis of equivocal orders as appropriate. However, because equivocal ordering represented less than 3% of all analyzed orders, including these as inappropriate would not have significantly altered our findings.
CONCLUSIONS
A review of thrombophilia testing practices at our institution demonstrated that inappropriate testing in the inpatient setting is a frequent phenomenon associated with a significant financial impact. This effect was more pronounced in inherited versus acquired thrombophilia testing. Testing was frequently confounded and often failed to impact patients’ short- or long-term clinical management, regardless of the result.
These findings serve as a strong impetus to reduce the burden of routine thrombophilia testing during hospital admissions. Our data demonstrate a need for institution-wide changes such as implementing best practice advisories, introducing ordering restrictions, and conducting educational interventions in order to reduce unnecessary expenditures and improve patient care.
Disclosure
The authors have nothing to disclose.
Venous thromboembolism (VTE) affects more than 1 million patients and costs the US healthcare system more than $1.5 billion annually.1 Inherited and acquired thrombophilias have been perceived as important risk factors in assessing the risk of VTE recurrence and guiding the duration of anticoagulation.
Thrombophilias increase the risk of a first thrombotic event, but existing data have failed to demonstrate the usefulness of routine thrombophilia screening on subsequent management.2,3 Moreover, thrombophilia testing ordered in the context of an inpatient hospitalization is limited by confounding factors, especially during an acute thrombotic event or in the setting of concurrent anticoagulation.4
Recognizing the costliness of routine thrombophilia testing, The American Society of Hematology introduced its Choosing Wisely campaign in 2013 in an effort to reduce test ordering in the setting of provoked VTEs with a major transient risk factor.5 In order to define current practice behavior at our institution, we conducted a retrospective study to determine the magnitude and financial impact of potentially inappropriate thrombophilia testing in the inpatient setting.
METHODS
We performed a retrospective analysis of thrombophilia testing across all inpatient services at a large, quaternary-care academic institution over a 2-year period. Electronic medical record data containing all thrombophilia tests ordered on inpatients from June 2013 to June 2015 were obtained. This study was exempt from institutional review board approval.
Inclusion criteria included any inpatient for which thrombophilia testing occurred. Patients were excluded if testing was ordered in the absence of VTE or arterial thrombosis or if it was ordered as part of a work-up for another medical condition (see Supplementary Material).
Thrombophilia testing was defined as any of the following: inherited thrombophilias (Factor V Leiden or prothrombin 20210 gene mutations, antithrombin, or protein C or S activity levels) or acquired thrombophilias (lupus anticoagulant [Testing refers to the activated partial thromboplastin time lupus assay.], beta-2 glycoprotein 1 immunoglobulins M and G, anticardiolipin immunoglobulins M and G, dilute Russell’s viper venom time, or JAK2 V617F mutations).
Extracted data included patient age, sex, type of thrombophilia test ordered, ordering primary service, admission diagnosis, and objective confirmation of thrombotic events. The indication for test ordering was determined via medical record review of the patient’s corresponding hospitalization. Each test was evaluated in the context of the patient’s presenting history, hospital course, active medications, accompanying laboratory and radiographic studies, and consultant recommendations to arrive at a conclusion regarding both the test’s reason for ordering and whether its indication was “inappropriate,” “appropriate,” or “equivocal.” Cost data were obtained through the Centers for Medicare & Medicaid Services (CMS) Clinical Laboratory Fee Schedule for 2016 (see Supplementary Material).6
The criteria for defining test appropriateness were formulated by utilizing a combination of major society guidelines and literature review.5,7-10 The criteria placed emphasis upon the ordered tests’ clinical relevance and reliability and were subsequently reviewed by a senior hematologist with specific expertise in thrombosis (see Supplementary Material).
Two internal medicine resident physician data reviewers independently evaluated the ordered tests. To ensure consistency between reviewers, a sample of identical test orders was compared for concordance, and a Cohen’s kappa coefficient was calculated. For purposes of analysis, equivocal orders were included under the appropriate category, as this study focused on the quantification of potentially inappropriate ordering practices. Pearson chi-square testing was performed in order to compare ordering practices between services using Stata.11
RESULTS
In total, we reviewed 2179 individual tests, of which 362 (16.6%) were excluded. The remaining 1817 tests involved 299 patients across 26 primary specialties. Fifty-two (2.9% of orders) were ultimately deemed equivocal. The Table illustrates the overall proportion and cost of inappropriate test ordering as well as testing characteristics of the most commonly encountered thrombotic diagnoses. The Figure illustrates the proportion of potentially inappropriate test ordering with its associated cost by test type.
Orders for Factor V Leiden, prothrombin 20210, and protein C and S activity levels were most commonly deemed inappropriate due to the test results’ failure to alter clinical management (97.3%, 99.2%, 99.4% of their inappropriate orders, respectively). Antithrombin testing (59.4%) was deemed inappropriate most commonly in the setting of acute thrombosis. The lupus anticoagulant (82.8%) was inappropriately ordered most frequently in the setting of concurrent anticoagulation.
Ordering practices were then compared between nonteaching and teaching inpatient general medicine services. We observed a higher proportion of inappropriate tests ordered by the nonteaching services as compared to the teaching services (120 of 173 orders [69.4%] versus 125 of 320 [39.1%], respectively; P < 0.001).
The interreviewer kappa coefficient was 0.82 (P < 0.0001).
DISCUSSION
This retrospective analysis represents one of the largest examinations of inpatient thrombophilia testing practices to date. Our results illustrate the high prevalence and significant financial impact of potentially inappropriate thrombophilia testing conducted in the inpatient setting. The data confirm that, per our defined criteria, more than 90% of inherited thrombophilia testing was potentially inappropriate while the majority of acquired thrombophilia testing was appropriate, with the exception of the lupus anticoagulant.
Even when appropriately ordered, studies suggest that positive thrombophilia screening results fail to impact outcomes in most patients with VTE. In an effort to evaluate positive results’ potential to provide a basis from which to extend the duration of anticoagulation, and therefore reduce the risk of a recurrent VTE, a case-control analysis was performed on a series of patients with a first-VTE event (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis [MEGA] study).3 In examining the odds ratio (OR) for recurrence between patients who did or did not undergo testing for Factor V Leiden, antithrombin, or protein C or S activity, the data failed to show an impact of testing on the risk of VTE recurrence (OR 1.2; confidence interval, 0.8-1.8). In fact, decision making has increasingly relied on patients’ clinical characteristics rather than thrombophilia test results to guide anticoagulation duration after incident VTEs. A 2017 study illustrated that when using a clinical decision rule (Clinical Decision Rule Validation Study to Predict Low Recurrent Risk in Patients With Unprovoked Venous Thromboembolism [REVERSE criteria]) in patients with a first, unprovoked VTE, routine thrombophilia screening added little to determining the need for prolonged anticoagulation.12 These findings support the limited clinical utility of current test ordering practices for the prediction and management of recurrent venous thrombosis.
Regarding the acquired thrombophilias, antiphospholipid antibody testing was predominantly ordered in a justified manner, which is consistent with the notion that test results could affect clinical management, such as anticoagulation duration or choice of anticoagulant.13 However, the validity of lupus anticoagulant testing was limited by the frequency of patients on concurrent anticoagulation.
Financially, the cumulative cost associated with inappropriate ordering was substantial, regardless of the thrombotic event in question. Moreover, our calculated costs are derived from CMS reimbursement rates and likely underestimate the true financial impact of errant testing given that commercial laboratories frequently charge at rates several-fold higher. On a national scale, prior analyses have suggested that the annual cost of thrombophilia testing, based on typical commercial rates, ranges from $300 million to $672 million.14
Researchers in prior studies have similarly examined the frequency of inappropriate thrombophilia testing and methods to reduce it. Researchers in a 2014 study demonstrated initially high rates of inappropriate inherited thrombophilia testing, and then showed marked reductions in testing and cost savings across multiple specialties following the introduction of a flowchart on a preprinted order form.15 Our findings provide motivation to perform similar endeavors.
The proportional difference of inappropriate ordering observed between nonteaching- and teaching-medicine services indicates a potential role for educational interventions. We recently completed a series of lectures on high-value thrombophilia ordering for residents and are actively analyzing its impact on subsequent ordering practices. We are also piloting an electronic best practice advisory for thrombophilia test ordering. Though the advisory may be overridden, providers are asked to provide justification for doing so on a voluntary basis. We plan to evaluate its effect on our findings reported in this study.
We acknowledge that our exclusion criteria resulted in the omission of testing across a spectrum of nonthrombotic clinical conditions, raising the question of selection bias. Because there are no established guidelines to determine the appropriateness of testing in these scenarios, we chose to limit the analysis of errant ordering to the context of thrombotic events. Other limitations of this study include the analysis of equivocal orders as appropriate. However, because equivocal ordering represented less than 3% of all analyzed orders, including these as inappropriate would not have significantly altered our findings.
CONCLUSIONS
A review of thrombophilia testing practices at our institution demonstrated that inappropriate testing in the inpatient setting is a frequent phenomenon associated with a significant financial impact. This effect was more pronounced in inherited versus acquired thrombophilia testing. Testing was frequently confounded and often failed to impact patients’ short- or long-term clinical management, regardless of the result.
These findings serve as a strong impetus to reduce the burden of routine thrombophilia testing during hospital admissions. Our data demonstrate a need for institution-wide changes such as implementing best practice advisories, introducing ordering restrictions, and conducting educational interventions in order to reduce unnecessary expenditures and improve patient care.
Disclosure
The authors have nothing to disclose.
1. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29(8):943-953. PubMed
2. Cohn DM, Vansenne F, de Borgie CA, Middeldorp S. Thrombophilia testing for prevention of recurrent venous thromboembolism. Cochrane Database Syst Rev. 2012;12:Cd007069. PubMed
3. Coppens M, Reijnders JH, Middeldorp S, Doggen CJ, Rosendaal FR. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost. 2008;6(9):1474-1477. PubMed
4. Somma J, Sussman, II, Rand JH. An evaluation of thrombophilia screening in an urban tertiary care medical center: A “real world” experience. Am J Clin Pathol. 2006;126(1):120-127. PubMed
5. Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood. 2013;122(24):3879-3883. PubMed
6. Centers for Medicare & Medicaid Services: Clinical Laboratory Fee Schedule Files. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html. Accessed October 2016
7. Stevens SM, Woller SC, Bauer KA, et al. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis. 2016;41(1):154-164. PubMed
8. Moll S. Thrombophilia: clinical-practical aspects. J Thromb Thrombolysis. 2015;39(3):367-378. PubMed
9. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for vte disease: Chest guideline and expert panel report. Chest. 2016;149(2):315-352. PubMed
10. Baglin T, Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010;149(2):209-220. PubMed
11. Stata Statistical Software [computer program]. Version Release 14. College Station, TX: StataCorp LP; 2015.
12. Garcia-Horton A, Kovacs MJ, Abdulrehman J, Taylor JE, Sharma S, Lazo-Langner A. Impact of thrombophilia screening on venous thromboembolism management practices. Thromb Res.149:76-80. PubMed
13. Schulman S, Svenungsson E, Granqvist S. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Duration of Anticoagulation Study Group. Am J Med. 1998;104(4):332-338. PubMed
14. Petrilli CM, Heidemann L, Mack M, Durance P, Chopra V. Inpatient inherited thrombophilia testing. J Hosp Med. 2016;11(11):801-804. PubMed
15. Smith TW, Pi D, Hudoba M, Lee AY. Reducing inpatient heritable thrombophilia testing using a clinical decision-making tool. J Clin Pathol. 2014;67(4):345-349. PubMed
1. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29(8):943-953. PubMed
2. Cohn DM, Vansenne F, de Borgie CA, Middeldorp S. Thrombophilia testing for prevention of recurrent venous thromboembolism. Cochrane Database Syst Rev. 2012;12:Cd007069. PubMed
3. Coppens M, Reijnders JH, Middeldorp S, Doggen CJ, Rosendaal FR. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost. 2008;6(9):1474-1477. PubMed
4. Somma J, Sussman, II, Rand JH. An evaluation of thrombophilia screening in an urban tertiary care medical center: A “real world” experience. Am J Clin Pathol. 2006;126(1):120-127. PubMed
5. Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood. 2013;122(24):3879-3883. PubMed
6. Centers for Medicare & Medicaid Services: Clinical Laboratory Fee Schedule Files. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html. Accessed October 2016
7. Stevens SM, Woller SC, Bauer KA, et al. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis. 2016;41(1):154-164. PubMed
8. Moll S. Thrombophilia: clinical-practical aspects. J Thromb Thrombolysis. 2015;39(3):367-378. PubMed
9. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for vte disease: Chest guideline and expert panel report. Chest. 2016;149(2):315-352. PubMed
10. Baglin T, Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010;149(2):209-220. PubMed
11. Stata Statistical Software [computer program]. Version Release 14. College Station, TX: StataCorp LP; 2015.
12. Garcia-Horton A, Kovacs MJ, Abdulrehman J, Taylor JE, Sharma S, Lazo-Langner A. Impact of thrombophilia screening on venous thromboembolism management practices. Thromb Res.149:76-80. PubMed
13. Schulman S, Svenungsson E, Granqvist S. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Duration of Anticoagulation Study Group. Am J Med. 1998;104(4):332-338. PubMed
14. Petrilli CM, Heidemann L, Mack M, Durance P, Chopra V. Inpatient inherited thrombophilia testing. J Hosp Med. 2016;11(11):801-804. PubMed
15. Smith TW, Pi D, Hudoba M, Lee AY. Reducing inpatient heritable thrombophilia testing using a clinical decision-making tool. J Clin Pathol. 2014;67(4):345-349. PubMed
© 2017 Society of Hospital Medicine
Resident‐Created Hospitalist Curriculum
Hospital medicine has grown tremendously since its inception in the 1990s.[1, 2] This expansion has led to the firm establishment of hospitalists in medical education, quality improvement (QI), research, subspecialty comanagement, and administration.[3, 4, 5]
This growth has also created new challenges. The training needs for the next generation of hospitalists are changing given the expanded clinical duties expected of hospitalists.[6, 7, 8] Prior surveys have suggested that some graduates employed as hospitalists have reported feeling underprepared in the areas of surgical comanagement, neurology, geriatrics, palliative care, and navigating the interdisciplinary care system.[9, 10]
In keeping with national trends, the number of residents interested in hospital medicine at our institution has dramatically increased. As internal medicine residents interested in careers in hospitalist medicine, we felt that improving hospitalist training at our institution was imperative given the increasing scope of practice and job competitiveness.[11, 12] We therefore sought to design and implement a hospitalist curriculum within our residency. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents.
METHODS
Needs Assessment
To improve hospitalist training at our institution, we first performed a needs assessment. We contacted recent hospitalist graduates and current faculty to identify aspects of their clinical duties that may have been underemphasized during their training. Next, we performed a literature search in PubMed using the combined terms of hospitalist, hospital medicine, residency, education, training gaps, or curriculum. Based on these efforts, we developed a resident survey that assessed their attitudes toward various components of a potential curriculum. The survey was sent to all categorical internal medicine residents at our institution in December 2014. The survey specified that the respondents only include those who were interested in careers in hospital medicine. Responses were measured using a 5‐point Likert scale (1 = least important to 5 = most important).
Curriculum Development
Our intention was to develop a well‐rounded program that utilized mentorship, research, and clinical experience to augment our learner's knowledge and skills for a successful, long‐term career in the increasingly competitive field of hospital medicine. When designing our curriculum, we accounted for our program's current rotational requirements and local culture. Several previously identified underemphasized areas within hospital medicine, such as palliative care and neurology, were already required rotations at our program.[3, 4, 5] Therefore, any proposed curricular changes would need to mold into program requirements while still providing a preparatory experience in hospital medicine beyond what our current rotations offered. We felt this could be accomplished by including rotations that could provide specific skills pertinent to hospital medicine, such as ultrasound diagnostics or QI.
| Rotation | Non‐SHAPE | SHAPE |
|---|---|---|
| ||
| ICU | At least 12 weeks | At least 16 weeks |
| Medical wards | At least 16 weeks | At least 16 weeks |
| Ultrasound diagnostics | Elective | Required |
| Quality improvement | Elective | Required |
| Surgical comanagement | Elective | Required |
| Medicine consult | Elective | Required |
| Neurology | Required | Required |
| Palliative care | Required | Required |
Meeting With Stakeholders
We presented our curriculum proposal to the chief of the Stanford Hospital Medicine Program. We identified her early in the process to be our primary mentor, and she proved instrumental in being an advocate. After several meetings with the hospitalist group to further develop our program, we presented it to the residency program leadership who helped us to finalize our program.
RESULTS
Needs Assessment
Twenty‐two out of 111 categorical residents in our program (19.8%) identified themselves as interested in hospital medicine and responded to the survey. There were several areas of a potential hospitalist curriculum that the residents identified as important (defined as 4 or 5 on a 5‐point Likert scale). These areas included mentorship (90.9% of residents; mean 4.6, standard deviation [SD] 0.7), opportunities to teach (86.3%; mean 4.4, SD 0.9), and the establishment of a formal hospitalist curriculum (85.7%; mean 4.2, SD 0.8). The residents also identified several rotations that would be beneficial (defined as a 4 or 5 on a 5‐point Likert scale). These included medicine consult/procedures team (95.5% of residents; mean 4.7, SD 0.6), point‐of‐care ultrasound diagnostics (90.8%; mean 4.7, SD 0.8), and a community hospitalist preceptorship (86.4%; mean 4.4, SD 1.0). The residents also identified several rotations deemed to be of lesser benefit. These rotations included inpatient neurology (only 27.3% of residents; mean 3.2, SD 0.8) and palliative care (50.0%; mean 3.5, SD 1.0).
The Final Product: A Hospitalist Training Curriculum
Based on the needs assessment and meetings with program leadership, we designed a hospitalist program and named it the Stanford Hospitalist Advanced Practice and Education (SHAPE) program. The program was based on 3 core principles: (1) clinical excellence: by training in hospitalist‐relevant clinical areas, (2) academic development: with required research, QI, and teaching, and (3) career mentorship.
Clinical Excellence By Training in Hospitalist‐Relevant Clinical Areas
The SHAPE curriculum builds off of our institution's current curriculum with additional required rotations to improve the resident's skillsets. These included ultrasound diagnostics, surgical comanagement, and QI (Box 1). Given that some hospitalists work in an open intensive care unit (ICU), we increased the amount of required ICU time to provide expanded procedural and critical care experiences. The residents also receive 10 seminars focused on hospital medicine, including patient safety, QI, and career development (Box 1).
Box
The Stanford Hospitalist Advanced Practice and Education (SHAPE) program curriculum. Members of the program are required to complete the requirements listed before the end of their third year. Note that the clinical rotations are spread over the 3 years of residency.
Stanford Hospitalist Advanced Practice and Education Required Clinical Rotations
- Medicine Consult (24 weeks)
- Critical Care (16 weeks)
- Ultrasound Diagnostics (2 weeks)
- Quality Improvement (4 weeks)
- Inpatient Neurology (2 weeks)
- Palliative Care (2 weeks)
- Surgical Comanagement (2 weeks)
Required Nonclinical Work
- Quality improvement, clinical or educational project with a presentation at an academic conference or manuscript submission in a peer‐reviewed journal
- Enrollment in the Stanford Faculty Development Center workshop on effective clinical teaching
- Attendance at the hospitalist lecture series (10 lectures): patient safety, hospital efficiency, fundamentals of perioperative medicine, healthcare structure and changing reimbursement patterns, patient handoff, career development, prevention of burnout, inpatient nutrition, hospitalist research, and lean modeling in the hospital setting
Mentorship
- Each participant is matched with 3 hospitalist mentors in order to provide comprehensive career and personal mentorship
Academic Development With Required Research and Teaching
SHAPE program residents are required to develop a QI, education, or clinical research project before graduation. They are required to present their work at a hospitalist conference or submit to a peer‐reviewed journal. They are also encouraged to attend the Society of Hospital Medicine annual meeting for their own career development.
SHAPE program residents also have increased opportunities to improve their teaching skills. The residents are enrolled in a clinical teaching workshop. Furthermore, the residents are responsible for leading regular lectures regarding common inpatient conditions for first‐ and second‐year medical students enrolled in a transitions‐of‐care elective.
Career Mentorship
Each resident is paired with 3 faculty hospitalists who have different areas of expertise (ie, clinical teaching, surgical comanagement, QI). They individually meet on a quarterly basis to discuss their career development and research projects. The SHAPE program will also host an annual resume‐development and career workshop.
SHAPE Resident Characteristics
In its first year, 13 of 25 residents (52%) interested in hospital medicine enrolled in the program. The SHAPE residents were predominantly second‐year residents (11 residents, 84.6%).
Among the 12 residents who did not enroll, there were 7 seniors (58.3%) who would soon be graduating and would not be eligible.
DISCUSSION
The training needs of aspiring hospitalists are changing as the scope of hospital medicine has expanded.[6] Residency programs can facilitate this by implementing a hospitalist curriculum that augments training and provides focused mentorship.[13, 14] An emphasis on resident leadership within these programs ensures positive housestaff buy‐in and satisfaction.
There were several key lessons we learned while designing our curriculum because of our unique role as residents and curriculum founders. This included the early engagement of departmental leadership as mentors. They assisted us in integrating our program within the existing internal medicine residency and the selection of electives. It was also imperative to secure adequate buy‐in from the academic hospitalists at our institution, as they would be our primary source of faculty mentors and lecturers.
A second challenge was balancing curriculum requirements and ensuring adequate buy‐in from our residents. The residents had fewer electives over their second and third years. However, this was balanced by the fact that the residents were given first preference on historically desirable rotations at our institution (including ultrasound, medicine consult, and QI). Furthermore, we purposefully included current resident opinions when performing our needs assessment to ensure adequate buy‐in. Surprisingly, the residents found several key rotations to be of low importance in our needs assessment, such as palliative care and inpatient neurology. Although this may seem confounding, several of these rotations (ie, neurology and palliative care) are already required of all residents at our program. It may be that some residents feel comfortable in these areas based on their previous experiences. Alternatively, this result may represent a lack of knowledge on the residents' part of what skill sets are imperative for career hospitalists. [4, 6]
Finally, we recognize that our program was based on our local needs assessment. Other residency programs may already have similar curricula built into their rotation schedule. In those instances, a hospitalist curriculum that emphasizes scholarly advancement and mentorship may be more appropriate.
CONCLUSIONS AND FUTURE DIRECTIONS
At out institution, we have created a hospitalist program designed to train the next generation of hospitalists with improved clinical, research, and teaching skills. Our cohort of residents will be observed over the next year, and we will administer a follow‐up study to assess the effectiveness of the program.
Acknowledgements
The authors acknowledge Karina Delgado, program manager at Stanford's internal medicine residency, for providing data on recent graduate plans.
Disclosures: Andre Kumar, MD, and Andrea Smeraglio, MD, are cofirst authors. The authors report no conflicts of interest.
- . The hospitalist field turns 15: new opportunities and challenges. J Hosp Med. 2011;6(4):10–13.
- , , , , . The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727–729.
- , , , . Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20(2):101–107.
- , , , . Survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999:343–349.
- , . Hospitalist educators: future of inpatient internal medicine training. Mt Sinai J Med. 2008;75(5):430–435.
- , , , , . Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008;23(7):1110–1115.
- , , , , . Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118(6):680–685
- , , , et al. Curricular content of internal medicine residency programs: a nationwide report. Am J Med. 2014;127(12):1247–1254.
- , , , . Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
- , , , et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's Task Force for Residency Reform. J Gen Intern Med. 2005;20(12):1165–1172.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , , , . Challenges and opportunities in academic hospital medicine: report from the Academic hospital medicine Summit. J Hosp Med. 2009;4(4):240–246.
- , , . Achieving hospital medicine's promise through internal medicine residency redesign. Mt Sinai J Med. 2008;75(5):436–441.
- , , , , . Training Future Hospitalists. Cult Med. 1999;171(12):367–370.
Hospital medicine has grown tremendously since its inception in the 1990s.[1, 2] This expansion has led to the firm establishment of hospitalists in medical education, quality improvement (QI), research, subspecialty comanagement, and administration.[3, 4, 5]
This growth has also created new challenges. The training needs for the next generation of hospitalists are changing given the expanded clinical duties expected of hospitalists.[6, 7, 8] Prior surveys have suggested that some graduates employed as hospitalists have reported feeling underprepared in the areas of surgical comanagement, neurology, geriatrics, palliative care, and navigating the interdisciplinary care system.[9, 10]
In keeping with national trends, the number of residents interested in hospital medicine at our institution has dramatically increased. As internal medicine residents interested in careers in hospitalist medicine, we felt that improving hospitalist training at our institution was imperative given the increasing scope of practice and job competitiveness.[11, 12] We therefore sought to design and implement a hospitalist curriculum within our residency. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents.
METHODS
Needs Assessment
To improve hospitalist training at our institution, we first performed a needs assessment. We contacted recent hospitalist graduates and current faculty to identify aspects of their clinical duties that may have been underemphasized during their training. Next, we performed a literature search in PubMed using the combined terms of hospitalist, hospital medicine, residency, education, training gaps, or curriculum. Based on these efforts, we developed a resident survey that assessed their attitudes toward various components of a potential curriculum. The survey was sent to all categorical internal medicine residents at our institution in December 2014. The survey specified that the respondents only include those who were interested in careers in hospital medicine. Responses were measured using a 5‐point Likert scale (1 = least important to 5 = most important).
Curriculum Development
Our intention was to develop a well‐rounded program that utilized mentorship, research, and clinical experience to augment our learner's knowledge and skills for a successful, long‐term career in the increasingly competitive field of hospital medicine. When designing our curriculum, we accounted for our program's current rotational requirements and local culture. Several previously identified underemphasized areas within hospital medicine, such as palliative care and neurology, were already required rotations at our program.[3, 4, 5] Therefore, any proposed curricular changes would need to mold into program requirements while still providing a preparatory experience in hospital medicine beyond what our current rotations offered. We felt this could be accomplished by including rotations that could provide specific skills pertinent to hospital medicine, such as ultrasound diagnostics or QI.
| Rotation | Non‐SHAPE | SHAPE |
|---|---|---|
| ||
| ICU | At least 12 weeks | At least 16 weeks |
| Medical wards | At least 16 weeks | At least 16 weeks |
| Ultrasound diagnostics | Elective | Required |
| Quality improvement | Elective | Required |
| Surgical comanagement | Elective | Required |
| Medicine consult | Elective | Required |
| Neurology | Required | Required |
| Palliative care | Required | Required |
Meeting With Stakeholders
We presented our curriculum proposal to the chief of the Stanford Hospital Medicine Program. We identified her early in the process to be our primary mentor, and she proved instrumental in being an advocate. After several meetings with the hospitalist group to further develop our program, we presented it to the residency program leadership who helped us to finalize our program.
RESULTS
Needs Assessment
Twenty‐two out of 111 categorical residents in our program (19.8%) identified themselves as interested in hospital medicine and responded to the survey. There were several areas of a potential hospitalist curriculum that the residents identified as important (defined as 4 or 5 on a 5‐point Likert scale). These areas included mentorship (90.9% of residents; mean 4.6, standard deviation [SD] 0.7), opportunities to teach (86.3%; mean 4.4, SD 0.9), and the establishment of a formal hospitalist curriculum (85.7%; mean 4.2, SD 0.8). The residents also identified several rotations that would be beneficial (defined as a 4 or 5 on a 5‐point Likert scale). These included medicine consult/procedures team (95.5% of residents; mean 4.7, SD 0.6), point‐of‐care ultrasound diagnostics (90.8%; mean 4.7, SD 0.8), and a community hospitalist preceptorship (86.4%; mean 4.4, SD 1.0). The residents also identified several rotations deemed to be of lesser benefit. These rotations included inpatient neurology (only 27.3% of residents; mean 3.2, SD 0.8) and palliative care (50.0%; mean 3.5, SD 1.0).
The Final Product: A Hospitalist Training Curriculum
Based on the needs assessment and meetings with program leadership, we designed a hospitalist program and named it the Stanford Hospitalist Advanced Practice and Education (SHAPE) program. The program was based on 3 core principles: (1) clinical excellence: by training in hospitalist‐relevant clinical areas, (2) academic development: with required research, QI, and teaching, and (3) career mentorship.
Clinical Excellence By Training in Hospitalist‐Relevant Clinical Areas
The SHAPE curriculum builds off of our institution's current curriculum with additional required rotations to improve the resident's skillsets. These included ultrasound diagnostics, surgical comanagement, and QI (Box 1). Given that some hospitalists work in an open intensive care unit (ICU), we increased the amount of required ICU time to provide expanded procedural and critical care experiences. The residents also receive 10 seminars focused on hospital medicine, including patient safety, QI, and career development (Box 1).
Box
The Stanford Hospitalist Advanced Practice and Education (SHAPE) program curriculum. Members of the program are required to complete the requirements listed before the end of their third year. Note that the clinical rotations are spread over the 3 years of residency.
Stanford Hospitalist Advanced Practice and Education Required Clinical Rotations
- Medicine Consult (24 weeks)
- Critical Care (16 weeks)
- Ultrasound Diagnostics (2 weeks)
- Quality Improvement (4 weeks)
- Inpatient Neurology (2 weeks)
- Palliative Care (2 weeks)
- Surgical Comanagement (2 weeks)
Required Nonclinical Work
- Quality improvement, clinical or educational project with a presentation at an academic conference or manuscript submission in a peer‐reviewed journal
- Enrollment in the Stanford Faculty Development Center workshop on effective clinical teaching
- Attendance at the hospitalist lecture series (10 lectures): patient safety, hospital efficiency, fundamentals of perioperative medicine, healthcare structure and changing reimbursement patterns, patient handoff, career development, prevention of burnout, inpatient nutrition, hospitalist research, and lean modeling in the hospital setting
Mentorship
- Each participant is matched with 3 hospitalist mentors in order to provide comprehensive career and personal mentorship
Academic Development With Required Research and Teaching
SHAPE program residents are required to develop a QI, education, or clinical research project before graduation. They are required to present their work at a hospitalist conference or submit to a peer‐reviewed journal. They are also encouraged to attend the Society of Hospital Medicine annual meeting for their own career development.
SHAPE program residents also have increased opportunities to improve their teaching skills. The residents are enrolled in a clinical teaching workshop. Furthermore, the residents are responsible for leading regular lectures regarding common inpatient conditions for first‐ and second‐year medical students enrolled in a transitions‐of‐care elective.
Career Mentorship
Each resident is paired with 3 faculty hospitalists who have different areas of expertise (ie, clinical teaching, surgical comanagement, QI). They individually meet on a quarterly basis to discuss their career development and research projects. The SHAPE program will also host an annual resume‐development and career workshop.
SHAPE Resident Characteristics
In its first year, 13 of 25 residents (52%) interested in hospital medicine enrolled in the program. The SHAPE residents were predominantly second‐year residents (11 residents, 84.6%).
Among the 12 residents who did not enroll, there were 7 seniors (58.3%) who would soon be graduating and would not be eligible.
DISCUSSION
The training needs of aspiring hospitalists are changing as the scope of hospital medicine has expanded.[6] Residency programs can facilitate this by implementing a hospitalist curriculum that augments training and provides focused mentorship.[13, 14] An emphasis on resident leadership within these programs ensures positive housestaff buy‐in and satisfaction.
There were several key lessons we learned while designing our curriculum because of our unique role as residents and curriculum founders. This included the early engagement of departmental leadership as mentors. They assisted us in integrating our program within the existing internal medicine residency and the selection of electives. It was also imperative to secure adequate buy‐in from the academic hospitalists at our institution, as they would be our primary source of faculty mentors and lecturers.
A second challenge was balancing curriculum requirements and ensuring adequate buy‐in from our residents. The residents had fewer electives over their second and third years. However, this was balanced by the fact that the residents were given first preference on historically desirable rotations at our institution (including ultrasound, medicine consult, and QI). Furthermore, we purposefully included current resident opinions when performing our needs assessment to ensure adequate buy‐in. Surprisingly, the residents found several key rotations to be of low importance in our needs assessment, such as palliative care and inpatient neurology. Although this may seem confounding, several of these rotations (ie, neurology and palliative care) are already required of all residents at our program. It may be that some residents feel comfortable in these areas based on their previous experiences. Alternatively, this result may represent a lack of knowledge on the residents' part of what skill sets are imperative for career hospitalists. [4, 6]
Finally, we recognize that our program was based on our local needs assessment. Other residency programs may already have similar curricula built into their rotation schedule. In those instances, a hospitalist curriculum that emphasizes scholarly advancement and mentorship may be more appropriate.
CONCLUSIONS AND FUTURE DIRECTIONS
At out institution, we have created a hospitalist program designed to train the next generation of hospitalists with improved clinical, research, and teaching skills. Our cohort of residents will be observed over the next year, and we will administer a follow‐up study to assess the effectiveness of the program.
Acknowledgements
The authors acknowledge Karina Delgado, program manager at Stanford's internal medicine residency, for providing data on recent graduate plans.
Disclosures: Andre Kumar, MD, and Andrea Smeraglio, MD, are cofirst authors. The authors report no conflicts of interest.
Hospital medicine has grown tremendously since its inception in the 1990s.[1, 2] This expansion has led to the firm establishment of hospitalists in medical education, quality improvement (QI), research, subspecialty comanagement, and administration.[3, 4, 5]
This growth has also created new challenges. The training needs for the next generation of hospitalists are changing given the expanded clinical duties expected of hospitalists.[6, 7, 8] Prior surveys have suggested that some graduates employed as hospitalists have reported feeling underprepared in the areas of surgical comanagement, neurology, geriatrics, palliative care, and navigating the interdisciplinary care system.[9, 10]
In keeping with national trends, the number of residents interested in hospital medicine at our institution has dramatically increased. As internal medicine residents interested in careers in hospitalist medicine, we felt that improving hospitalist training at our institution was imperative given the increasing scope of practice and job competitiveness.[11, 12] We therefore sought to design and implement a hospitalist curriculum within our residency. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents.
METHODS
Needs Assessment
To improve hospitalist training at our institution, we first performed a needs assessment. We contacted recent hospitalist graduates and current faculty to identify aspects of their clinical duties that may have been underemphasized during their training. Next, we performed a literature search in PubMed using the combined terms of hospitalist, hospital medicine, residency, education, training gaps, or curriculum. Based on these efforts, we developed a resident survey that assessed their attitudes toward various components of a potential curriculum. The survey was sent to all categorical internal medicine residents at our institution in December 2014. The survey specified that the respondents only include those who were interested in careers in hospital medicine. Responses were measured using a 5‐point Likert scale (1 = least important to 5 = most important).
Curriculum Development
Our intention was to develop a well‐rounded program that utilized mentorship, research, and clinical experience to augment our learner's knowledge and skills for a successful, long‐term career in the increasingly competitive field of hospital medicine. When designing our curriculum, we accounted for our program's current rotational requirements and local culture. Several previously identified underemphasized areas within hospital medicine, such as palliative care and neurology, were already required rotations at our program.[3, 4, 5] Therefore, any proposed curricular changes would need to mold into program requirements while still providing a preparatory experience in hospital medicine beyond what our current rotations offered. We felt this could be accomplished by including rotations that could provide specific skills pertinent to hospital medicine, such as ultrasound diagnostics or QI.
| Rotation | Non‐SHAPE | SHAPE |
|---|---|---|
| ||
| ICU | At least 12 weeks | At least 16 weeks |
| Medical wards | At least 16 weeks | At least 16 weeks |
| Ultrasound diagnostics | Elective | Required |
| Quality improvement | Elective | Required |
| Surgical comanagement | Elective | Required |
| Medicine consult | Elective | Required |
| Neurology | Required | Required |
| Palliative care | Required | Required |
Meeting With Stakeholders
We presented our curriculum proposal to the chief of the Stanford Hospital Medicine Program. We identified her early in the process to be our primary mentor, and she proved instrumental in being an advocate. After several meetings with the hospitalist group to further develop our program, we presented it to the residency program leadership who helped us to finalize our program.
RESULTS
Needs Assessment
Twenty‐two out of 111 categorical residents in our program (19.8%) identified themselves as interested in hospital medicine and responded to the survey. There were several areas of a potential hospitalist curriculum that the residents identified as important (defined as 4 or 5 on a 5‐point Likert scale). These areas included mentorship (90.9% of residents; mean 4.6, standard deviation [SD] 0.7), opportunities to teach (86.3%; mean 4.4, SD 0.9), and the establishment of a formal hospitalist curriculum (85.7%; mean 4.2, SD 0.8). The residents also identified several rotations that would be beneficial (defined as a 4 or 5 on a 5‐point Likert scale). These included medicine consult/procedures team (95.5% of residents; mean 4.7, SD 0.6), point‐of‐care ultrasound diagnostics (90.8%; mean 4.7, SD 0.8), and a community hospitalist preceptorship (86.4%; mean 4.4, SD 1.0). The residents also identified several rotations deemed to be of lesser benefit. These rotations included inpatient neurology (only 27.3% of residents; mean 3.2, SD 0.8) and palliative care (50.0%; mean 3.5, SD 1.0).
The Final Product: A Hospitalist Training Curriculum
Based on the needs assessment and meetings with program leadership, we designed a hospitalist program and named it the Stanford Hospitalist Advanced Practice and Education (SHAPE) program. The program was based on 3 core principles: (1) clinical excellence: by training in hospitalist‐relevant clinical areas, (2) academic development: with required research, QI, and teaching, and (3) career mentorship.
Clinical Excellence By Training in Hospitalist‐Relevant Clinical Areas
The SHAPE curriculum builds off of our institution's current curriculum with additional required rotations to improve the resident's skillsets. These included ultrasound diagnostics, surgical comanagement, and QI (Box 1). Given that some hospitalists work in an open intensive care unit (ICU), we increased the amount of required ICU time to provide expanded procedural and critical care experiences. The residents also receive 10 seminars focused on hospital medicine, including patient safety, QI, and career development (Box 1).
Box
The Stanford Hospitalist Advanced Practice and Education (SHAPE) program curriculum. Members of the program are required to complete the requirements listed before the end of their third year. Note that the clinical rotations are spread over the 3 years of residency.
Stanford Hospitalist Advanced Practice and Education Required Clinical Rotations
- Medicine Consult (24 weeks)
- Critical Care (16 weeks)
- Ultrasound Diagnostics (2 weeks)
- Quality Improvement (4 weeks)
- Inpatient Neurology (2 weeks)
- Palliative Care (2 weeks)
- Surgical Comanagement (2 weeks)
Required Nonclinical Work
- Quality improvement, clinical or educational project with a presentation at an academic conference or manuscript submission in a peer‐reviewed journal
- Enrollment in the Stanford Faculty Development Center workshop on effective clinical teaching
- Attendance at the hospitalist lecture series (10 lectures): patient safety, hospital efficiency, fundamentals of perioperative medicine, healthcare structure and changing reimbursement patterns, patient handoff, career development, prevention of burnout, inpatient nutrition, hospitalist research, and lean modeling in the hospital setting
Mentorship
- Each participant is matched with 3 hospitalist mentors in order to provide comprehensive career and personal mentorship
Academic Development With Required Research and Teaching
SHAPE program residents are required to develop a QI, education, or clinical research project before graduation. They are required to present their work at a hospitalist conference or submit to a peer‐reviewed journal. They are also encouraged to attend the Society of Hospital Medicine annual meeting for their own career development.
SHAPE program residents also have increased opportunities to improve their teaching skills. The residents are enrolled in a clinical teaching workshop. Furthermore, the residents are responsible for leading regular lectures regarding common inpatient conditions for first‐ and second‐year medical students enrolled in a transitions‐of‐care elective.
Career Mentorship
Each resident is paired with 3 faculty hospitalists who have different areas of expertise (ie, clinical teaching, surgical comanagement, QI). They individually meet on a quarterly basis to discuss their career development and research projects. The SHAPE program will also host an annual resume‐development and career workshop.
SHAPE Resident Characteristics
In its first year, 13 of 25 residents (52%) interested in hospital medicine enrolled in the program. The SHAPE residents were predominantly second‐year residents (11 residents, 84.6%).
Among the 12 residents who did not enroll, there were 7 seniors (58.3%) who would soon be graduating and would not be eligible.
DISCUSSION
The training needs of aspiring hospitalists are changing as the scope of hospital medicine has expanded.[6] Residency programs can facilitate this by implementing a hospitalist curriculum that augments training and provides focused mentorship.[13, 14] An emphasis on resident leadership within these programs ensures positive housestaff buy‐in and satisfaction.
There were several key lessons we learned while designing our curriculum because of our unique role as residents and curriculum founders. This included the early engagement of departmental leadership as mentors. They assisted us in integrating our program within the existing internal medicine residency and the selection of electives. It was also imperative to secure adequate buy‐in from the academic hospitalists at our institution, as they would be our primary source of faculty mentors and lecturers.
A second challenge was balancing curriculum requirements and ensuring adequate buy‐in from our residents. The residents had fewer electives over their second and third years. However, this was balanced by the fact that the residents were given first preference on historically desirable rotations at our institution (including ultrasound, medicine consult, and QI). Furthermore, we purposefully included current resident opinions when performing our needs assessment to ensure adequate buy‐in. Surprisingly, the residents found several key rotations to be of low importance in our needs assessment, such as palliative care and inpatient neurology. Although this may seem confounding, several of these rotations (ie, neurology and palliative care) are already required of all residents at our program. It may be that some residents feel comfortable in these areas based on their previous experiences. Alternatively, this result may represent a lack of knowledge on the residents' part of what skill sets are imperative for career hospitalists. [4, 6]
Finally, we recognize that our program was based on our local needs assessment. Other residency programs may already have similar curricula built into their rotation schedule. In those instances, a hospitalist curriculum that emphasizes scholarly advancement and mentorship may be more appropriate.
CONCLUSIONS AND FUTURE DIRECTIONS
At out institution, we have created a hospitalist program designed to train the next generation of hospitalists with improved clinical, research, and teaching skills. Our cohort of residents will be observed over the next year, and we will administer a follow‐up study to assess the effectiveness of the program.
Acknowledgements
The authors acknowledge Karina Delgado, program manager at Stanford's internal medicine residency, for providing data on recent graduate plans.
Disclosures: Andre Kumar, MD, and Andrea Smeraglio, MD, are cofirst authors. The authors report no conflicts of interest.
- . The hospitalist field turns 15: new opportunities and challenges. J Hosp Med. 2011;6(4):10–13.
- , , , , . The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727–729.
- , , , . Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20(2):101–107.
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- , , , . Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
- , , , et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's Task Force for Residency Reform. J Gen Intern Med. 2005;20(12):1165–1172.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , , , . Challenges and opportunities in academic hospital medicine: report from the Academic hospital medicine Summit. J Hosp Med. 2009;4(4):240–246.
- , , . Achieving hospital medicine's promise through internal medicine residency redesign. Mt Sinai J Med. 2008;75(5):436–441.
- , , , , . Training Future Hospitalists. Cult Med. 1999;171(12):367–370.
- . The hospitalist field turns 15: new opportunities and challenges. J Hosp Med. 2011;6(4):10–13.
- , , , , . The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727–729.
- , , , . Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20(2):101–107.
- , , , . Survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999:343–349.
- , . Hospitalist educators: future of inpatient internal medicine training. Mt Sinai J Med. 2008;75(5):430–435.
- , , , , . Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008;23(7):1110–1115.
- , , , , . Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118(6):680–685
- , , , et al. Curricular content of internal medicine residency programs: a nationwide report. Am J Med. 2014;127(12):1247–1254.
- , , , . Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
- , , , et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's Task Force for Residency Reform. J Gen Intern Med. 2005;20(12):1165–1172.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , , , . Challenges and opportunities in academic hospital medicine: report from the Academic hospital medicine Summit. J Hosp Med. 2009;4(4):240–246.
- , , . Achieving hospital medicine's promise through internal medicine residency redesign. Mt Sinai J Med. 2008;75(5):436–441.
- , , , , . Training Future Hospitalists. Cult Med. 1999;171(12):367–370.