Brian Markoff, MD

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Literature at a Glance

• Drug-eluting stents decrease the need for revascularization.
• Case volume is related to hospital performance assessment.
• Prolonged QRS duration in patients with CHF is associated with increased morbidity and mortality.
• For out-of-hospital ACLS, vasopressin plus epinephrine is not better than vasopressin alone.
• Oral rivaroxaban is more efficacious than enoxaparin for VTE prophylaxis after total hip replacement.
• LMWH and UFH offer similar perioperative VTE prophylaxis benefit in patients with cancer.
• Salmeterol added to inhaled corticosteroids decreases severe asthma exacerbations.
• Early invasive strategy has unclear benefit in low-risk women with unstable angina or NSTEMI.
• Strategies to prevent contrast-induced acute kidney injury are not uniform.
• Hyperglycemia in hospitalized children is common and associated with ICU admission.

Do drug-eluting stents improve outcomes after ST-elevation myocardial infarction (STEMI)?

Background: Drug-eluting stents reduce restenosis rates compared to bare-metal stents. However, there is concern drug-eluting stents increase the risk of stent thrombosis leading to MI and death. Prior studies compared patients who received bare-metal versus those who received drug-eluting stents. Outcomes on a population level might provide new insight.

Study design: Observational study.

Setting: 100% national sample of patients 65 and older who received a coronary stent from 2002-05 enrolled in the traditional fee-for-service Medicare program.

Synopsis: 38,917 patients in the pre-drug-eluting-stent era from October 2002 to March 2003 received bare-metal stents. Nearly 62% of 28,086 patients studied from September to December 2003 received drug-eluting stents. The remaining 38.5% received bare-metal stents. Outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), STEMI, and death were observed through December 31, 2005.

Patients in the drug-eluting-stent era had a lower two-year risk for repeat revascularization compared to patients in the bare-metal-stent era. In the drug-eluting versus bare-metal eras, repeat PCI was 17.1% versus 20.0% (p<0.001) and need for CABG was 2.7% versus 4.2% (p<0.01). Comparing adjusted outcomes for death, or STEMI, at two years, the two groups appeared similar.

The study did have limitations: the data only reflect sirolimus stents, the authors could not assess dual-antiplatelet therapy or obtain information on coronary anatomy or procedure details to account for selection bias in stent utilization, and the patients were all Medicare beneficiaries.

Bottom line: Drug-eluting stents are associated with fewer repeat revascularization procedures than bare-metal stents, but have not shown a significant improvement in the subsequent risk of STEMI or death.

Citation: Malenka DJ, Kaplan AV, Lucas FL, Sharp SM, Skinner JA. Outcomes following coronary stenting in the era of bare-metal vs. the era of drug-eluting stents. JAMA 2008;299(24):2868-2877.

Does case volume affect hospital performance for publicly reported process measures?

Background: Hospitals are increasingly graded and compared to one another. “Top medical centers” are defined as those within the top 10% of hospitals in specified performance measures. Hospitals with large and small case volumes might not be compared evenly and fairly.

Study design: Eight publicly reported process measures for acute myocardial infarction (AMI) were compared to hospital case volume, process performance, and label as “top hospital.”

Setting: Data were analyzed from the Hospital Quality Alliance for 3,761 hospitals from January to December 2005.

Synopsis: Hospitals with large case volume overall had better process performance. For example, looking at use of beta-blockers in patients with AMI on arrival to a hospital, small-volume hospitals (<10 AMI cases) averaged 72% while large volume (>100 AMI cases) averaged 80% (p<0.001). However, hospitals with small case volumes were more likely to receive “top hospital” rating even when hospitals with very low case volumes were excluded.

Hospital quality reporting that does not account for case volume is misleading to hospitals and consumers. In this study, larger-volume hospitals appeared to perform better in process measures, but were less likely to receive “top hospital” rating.

Bottom line: Hospitals with large and small case volumes can easily be compared to one another for process measures in AMI.

Citation: O’Brien SM, DeLong ER, Peterson ED. Impact of case volume on hospital performance assessment. Arch Intern Med. 2008;168(12):1277-1284.

What is the predictive value of QRS duration in patients hospitalized with worsening CHF?

Background: In outpatients, a prolonged QRS duration (greater than 120 ms) is associated with increased mortality. Its value in the inpatient setting is unclear. For patients hospitalized with CHF exacerbations, establishing the value of QRS duration may allow for tailored management.

Study design: Retrospective post hoc analysis from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST).

Setting: 4,133 patients were enrolled from North American, South American, and European sites.

Synopsis: Of 2,962 patients included in the final post hoc analysis, 1,321 (44.6%) had a prolonged QRS duration. During a median follow up of 9.9 months, the all-cause mortality rate was 18.7% for patients with a normal baseline QRS duration and 28.1% for patients with a prolonged baseline QRS.

After adjusting for confounding variables, patients with a prolonged baseline QRS had a 24% increased risk of all-cause mortality and a 28% increased risk for a composite endpoint of cardiac mortality or hospitalization for heart failure exacerbation.

The retrospective nature of the analysis represents the major limitation of this study. In addition, most of the enrolled patients were white, which limits the studies generalizability to other ethnic groups.

Bottom Line: A prolonged QRS duration for patients admitted with decompensated left ventricular heart failure is common and may be associated with increased morbidity and mortality.

Citation: Wang NC, Maggioni AP, Konstam MA, Zannad F, Drasa HB, Burnett JC, et al. Clinical implications of QRS duration in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction. JAMA. 2008;299(22):2656-2666.

For patients with out-of-hospital cardiac arrest, does the addition of vasopressin to epinephrine in a protocol for ACLS improve outcomes?

Background: The outcome for patients experiencing cardiac arrest who require vasopressors remains extremely poor. Despite disappointing data on vasopressin as an alternative treatment during cardiac arrest, a recent subgroup analysis suggested patients who received epinephrine and vasopressin together had superior clinical outcomes.

Study Design: Prospective multicenter randomized double-blind controlled trial.

Setting: 31 emergency medical service organizations in France.

Synopsis: Of the 2,894 patients, 20.7% of those receiving combination treatment (vasopressin plus epinephrine) survived to hospital admission versus 21.3% of those in the epinephrine-only group. For those same groups, 1.7% of combination and 2.3% of epinephrine-only patients survived to hospital discharge. No significant outcome differences were found in any group or subgroup analysis.

The study had lower-than-expected overall survival to hospital discharge, which may have handicapped its effort to find a true difference in treatment arms.

Bottom line: The addition of vasopressin to epinephrine in the treatment of out-of-hospital cardiac arrest does not improve outcomes.

Citation: Gueugniaud PY, David JS, Chanzy E, Hubert H, Dubien P, Mauriaucourt P, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359(1):21-30.

Is oral rivaroxaban more efficacious than subcutaneous enoxaparin in preventing VTE after hip-replacement surgery?

Background: Venous thromboembolism (VTE) prophylaxis after total hip replacement (THR) is important but can be cumbersome because the most commonly used anticoagulants are either subcutaneous or require frequent monitoring. Rivaroxaban, an oral direct inhibitor of factor Xa may provide more convenient anticoagulation postoperatively. However, its efficacy and safety are unknown.

Study design: Randomized double-blind trial.

Setting: Multicenter study performed in 27 countries.

Synopsis: Patients undergoing THR surgery were randomized to oral rivaroxaban (10mg once daily without monitoring, started six to eight hours after surgery) or subcutaneous enoxaparin (40mg once daily, started 12 hours prior to surgery). After surgery, prophylaxis was administered for 35 days. The primary outcome was a composite of asymptomatic deep venous thrombosis (DVT), symptomatic DVT or pulmonary embolism (PE), or death from any cause at 36 days after surgery.

In the enoxaparin group, 3.7% of patients experienced the primary outcome. This decreased to 1.1% in the rivaroxaban group. Approximately one-third of events were symptomatic. Major bleeding occurred in 0.1% and 0.3% (p=NS) of patients in the enoxaparin and rivaroxaban groups, respectively.

The study is limited by the exclusion of 1,388 of the 4,541 patients (30.6%) randomized, primarily due to having inadequate venography. Also, because the majority of thromboembolic events were asymptomatic, the primary outcome overemphasizes the clinical difference.

Bottom line: Oral rivaroxaban without monitoring is more efficacious than, and as safe as, subcutaneous enoxaparin when used for VTE prophylaxis for THR.

Citation: Eriksson B, Borris LC, Friedman RJ, Hass S, Huisman MV, Kakkar AK, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358:2765-75.

Is LMWH more efficacious than UFH in preventing postoperative VTE in cancer patients?

Background: Patients with cancer are at increased risk for VTE and require prophylaxis to prevent this complication postoperatively. Low molecular weight heparin (LMWH) has proven more efficacious than subcutaneous unfractionated heparin (UFH) in other settings (e.g., DVT treatment). However, it is still unknown whether LMWH offers better prophylaxis compared to UFH for cancer patients undergoing surgery.

Study design: Systematic review and meta-analysis.

Setting: 14 randomized controlled trials.

Synopsis: Eleven trials exclusively examined patients with cancer (n=4006) and three trials reported data for cancer patients as subgroups (n=1816). There were in differences in mortality, pulmonary embolism, and symptomatic DVT rates between the two groups.

LMWH was associated with a decrease in total (asymptomatic or symptomatic) DVT (RR, 0.72; 95% CI, 0.55-0.94). Rates of major bleeding, minor bleeding, and intraoperative blood loss were similar between the two treatments.

This meta-analysis is limited because 12 remaining trials (n=3185) also enrolled cancer patients but did not provide specific data for the cancer patient subgroup. The study also is limited by the heterogeneity of the original trials, including utilizing varying LMWHs and dosing regimens, numerous types of surgeries, and a wide range of neoplasms.

Bottom line: LMWH does not decrease mortality, pulmonary embolism, or symptomatic DVT compared to UFH in cancer patients undergoing surgery.

Citation: Akl EA, Terrenato I, Barba M, Sperati F, Sempos EV, Muti P, et al. Low-molecular-weight heparin vs. unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Arch Intern Med. 2008;168:1261-9.

Does salmeterol added to inhaled corticosteroids improve severe asthma-related events?

Background: Asthma is a chronic disease causing major morbidity and mortality worldwide. Disease guidelines recommend all patients with persistent asthma be treated with inhaled corticosteroids. These same guidelines recommend adding a long-acting beta-agonist for patients whose symptoms persist. However, the safety of this practice has come under scrutiny.

Study design: Meta-analysis.

Setting: Sixty-six randomized, controlled trials conducted worldwide.

Synopsis: Analysis included 66 GlaxoSmithKline trials with a total of 20,966 patients with persistent asthma. Patients used either salmeterol (50mcg twice daily) plus inhaled corticosteroid (10,400 patients) or inhaled corticosteroid alone (10,566 patients).

Results showed no differences in asthma-related hospitalizations, asthma-related intubations, or deaths between the two groups. However, due to the low number of events, definitive conclusions are difficult to make. Severe asthma exacerbations requiring systemic corticosteroids significantly decreased in the inhaled corticosteroid plus salmeterol group.

The study is limited by it inclusion of only those trials sponsored by GlaxoSmithKline and by the short duration of most of the studies. Additionally, the studies included in the analysis used clinical outcomes as secondary endpoints.

Bottom line: Adding salmeterol to inhaled corticosteroid decreases severe asthma exacerbations and is likely safe, but does not have an effect on asthma-related hospitalization or death.

Citation: Bateman E, Nelson H, Bousquet J, Kral K, Sutton L, Ortega H, et.al. Meta-analysis: Effects of adding salmeterol to inhaled corticosteroids on serious asthma-related events. Annals Intern Med. 2008;149:33-42.

Is an early invasive strategy effective in women with unstable angina or NSTEMI?

Background: Despite many trials showing the value of an early invasive strategy for patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS), data from several trials question this benefit in women. Some trials show higher risk of death and myocardial infarction (MI) in subgroup analysis of women.

Study Design: Meta-analysis.

Setting: Eight randomized, controlled trials conducted worldwide.

Synopsis: Analysis included eight trials with 10,412 patients (3,075 women) with NSTE ACS. The invasive group (5,083 patients) was defined as those referred for coronary angiography with subsequent intervention as needed. The composite endpoint of death, MI, or rehospitalization within 12 months with ACS occurred in 21.1% of the invasive group and 25.9% of the medically managed group (OR, 0.78; CI, 0.61-0.98).

The subgroup, including only women, had a non-statistically significant OR of 0.81 (CI, 0.65-1.01), including no effect on all-cause mortality, nonfatal MI, or the composite of death and MI. However, women with high-risk features (elevated biomarkers) undergoing the invasive strategy had a significant reduction in the composite endpoint (OR, 0.67; CI, 0.50-0.88).

The study is limited by the use of subgroup analysis, secondary endpoints, heterogeneity between trials, and possible publication bias.

Bottom line: Early invasive strategy is effective in men and high-risk women with NSTE ACS, but not in low-risk women.

Citation: O’Donoghue M, Boden W, Braunwald E, Cannon CP, Clayton TC, Winter RJ, et.al. Early invasive vs. conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction. JAMA. 2008;300:71-80.

What strategies are used to prevent contrast-induced acute kidney injury?

Background: Contrast-induced acute kidney injury (CIAKI) is a condition potentially amenable to preventive care. Several trials have identified intravenous hydration, N-acetylcysteine, and withdrawal of NSAIDS as interventions that reduce the possibility of CIAKI in high-risk patients. Little is known about whether healthcare providers routinely use these strategies.

Study design: Prospective observational cohort study.

Setting: Veterans Affairs (VA) Pittsburgh Healthcare System.

Synopsis: 11,410 patients scheduled for radiographic procedures were screened. After exclusion criteria and eligibility, 660 patients with an estimated glomerular filtration rate less than 60ml/min/1.73m2 were identified. Usage of intravenous fluids, N-acetylcysteine, and discontinuation of NSAIDS were recorded. Serum creatinine (SCr) was measured 48 to 96 hours post-procedure. CIAKI was defined as relative increase in SCr from baseline (≥25%, ≥50% and ≥100%) and absolute increase in SCr levels from baseline (≥0.25, ≥0.5, and ≥1.0). CIAKI association with adverse outcomes was evaluated by tracking 30-day mortality, need for dialysis, and hospitalization.

The incidence of CIAKI was less common in patients undergoing CT scans versus those having angiograms. Adverse 30-day outcomes were uncommon. Pre- and post-procedure intravenous hydration was administered to 40% of study patients, more commonly with coronary angiogram than with computed tomography (91.2% vs. 16%, p<0.0001). N-acetylcysteine was administered to 39.2%. Only 6.8% of those taking NSAIDS reported being told to discontinue the medication.

Study limitations include the small sample size and the single site location, both limiting generalizability.

Bottom line: Clinically significant CIAKI is uncommon, and preventive care is not uniformly implemented in patients undergoing contrast-enhanced radiographic procedures.

Citation: Weisbord SD, Mor MK, Resnick AL, Hartwig KC, Sonel AF, Fine MJ, et al. Prevention, incidence, and outcomes of contrast-induced acute kidney injury. Arch Intern Med. 2008;168(12):1325-1332.

How does hyperglycemia affect morbidity and mortality in children admitted to a community pediatric hospital?

Background: Inpatient hyperglycemia in adult patients is a predictor of poor clinical outcomes. The association of hyperglycemia and clinical outcomes in children admitted to a general community hospital has not been studied.

Study design: Retrospective observational cohort study.

Setting: A community pediatric hospital in Atlanta, Ga.

Synopsis: Review of medical records of 903 consecutive pediatric patients admitted to critical and non-critical areas took place. Of these, 542 patients constituted the study population. The study excluded 342 patients who didn’t have a blood glucose measurement. Hyperglycemia was defined as an admission or in-hospital blood glucose greater than 120mg/dl.

One-fourth of the children admitted to the hospital had hyperglycemia, most without a prior history of diabetes. The presence of hyperglycemia on admission was not associated with increased length of stay (LOS) or increased mortality. Children with hyperglycemia were more likely to be admitted to the ICU and had longer ICU LOS.

This was a retrospective study conducted at a single site whose demographics and disease spectrum may differ from those of other institutions. There were an insufficient number of deaths to make any conclusions regarding the impact of hyperglycemia on mortality. Prospective, randomized, multicenter trials are needed to better elucidate the effects of in-patient hyperglycemia.

Bottom line: Hyperglycemia is common in children with or without diabetes admitted to the hospital, and is associated with increased ICU admissions and ICU length of stay. Its connection to mortality is inconclusive.

Citation: Palaio A, Smiley D, Ceron M, Klein R, Cho IS, Mejia R, et al. Prevalence and clinical outcome of inpatient hyperglycemia in a community pediatric hospital. J Hosp Med.2008;3(3):212-217.

Literature at a Glance

• Drug-eluting stents decrease the need for revascularization.
• Case volume is related to hospital performance assessment.
• Prolonged QRS duration in patients with CHF is associated with increased morbidity and mortality.
• For out-of-hospital ACLS, vasopressin plus epinephrine is not better than vasopressin alone.
• Oral rivaroxaban is more efficacious than enoxaparin for VTE prophylaxis after total hip replacement.
• LMWH and UFH offer similar perioperative VTE prophylaxis benefit in patients with cancer.
• Salmeterol added to inhaled corticosteroids decreases severe asthma exacerbations.
• Early invasive strategy has unclear benefit in low-risk women with unstable angina or NSTEMI.
• Strategies to prevent contrast-induced acute kidney injury are not uniform.
• Hyperglycemia in hospitalized children is common and associated with ICU admission.

Do drug-eluting stents improve outcomes after ST-elevation myocardial infarction (STEMI)?

Background: Drug-eluting stents reduce restenosis rates compared to bare-metal stents. However, there is concern drug-eluting stents increase the risk of stent thrombosis leading to MI and death. Prior studies compared patients who received bare-metal versus those who received drug-eluting stents. Outcomes on a population level might provide new insight.

Study design: Observational study.

Setting: 100% national sample of patients 65 and older who received a coronary stent from 2002-05 enrolled in the traditional fee-for-service Medicare program.

Synopsis: 38,917 patients in the pre-drug-eluting-stent era from October 2002 to March 2003 received bare-metal stents. Nearly 62% of 28,086 patients studied from September to December 2003 received drug-eluting stents. The remaining 38.5% received bare-metal stents. Outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), STEMI, and death were observed through December 31, 2005.

Patients in the drug-eluting-stent era had a lower two-year risk for repeat revascularization compared to patients in the bare-metal-stent era. In the drug-eluting versus bare-metal eras, repeat PCI was 17.1% versus 20.0% (p<0.001) and need for CABG was 2.7% versus 4.2% (p<0.01). Comparing adjusted outcomes for death, or STEMI, at two years, the two groups appeared similar.

The study did have limitations: the data only reflect sirolimus stents, the authors could not assess dual-antiplatelet therapy or obtain information on coronary anatomy or procedure details to account for selection bias in stent utilization, and the patients were all Medicare beneficiaries.

Bottom line: Drug-eluting stents are associated with fewer repeat revascularization procedures than bare-metal stents, but have not shown a significant improvement in the subsequent risk of STEMI or death.

Citation: Malenka DJ, Kaplan AV, Lucas FL, Sharp SM, Skinner JA. Outcomes following coronary stenting in the era of bare-metal vs. the era of drug-eluting stents. JAMA 2008;299(24):2868-2877.

Does case volume affect hospital performance for publicly reported process measures?

Background: Hospitals are increasingly graded and compared to one another. “Top medical centers” are defined as those within the top 10% of hospitals in specified performance measures. Hospitals with large and small case volumes might not be compared evenly and fairly.

Study design: Eight publicly reported process measures for acute myocardial infarction (AMI) were compared to hospital case volume, process performance, and label as “top hospital.”

Setting: Data were analyzed from the Hospital Quality Alliance for 3,761 hospitals from January to December 2005.

Synopsis: Hospitals with large case volume overall had better process performance. For example, looking at use of beta-blockers in patients with AMI on arrival to a hospital, small-volume hospitals (<10 AMI cases) averaged 72% while large volume (>100 AMI cases) averaged 80% (p<0.001). However, hospitals with small case volumes were more likely to receive “top hospital” rating even when hospitals with very low case volumes were excluded.

Hospital quality reporting that does not account for case volume is misleading to hospitals and consumers. In this study, larger-volume hospitals appeared to perform better in process measures, but were less likely to receive “top hospital” rating.

Bottom line: Hospitals with large and small case volumes can easily be compared to one another for process measures in AMI.

Citation: O’Brien SM, DeLong ER, Peterson ED. Impact of case volume on hospital performance assessment. Arch Intern Med. 2008;168(12):1277-1284.

What is the predictive value of QRS duration in patients hospitalized with worsening CHF?

Background: In outpatients, a prolonged QRS duration (greater than 120 ms) is associated with increased mortality. Its value in the inpatient setting is unclear. For patients hospitalized with CHF exacerbations, establishing the value of QRS duration may allow for tailored management.

Study design: Retrospective post hoc analysis from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST).

Setting: 4,133 patients were enrolled from North American, South American, and European sites.

Synopsis: Of 2,962 patients included in the final post hoc analysis, 1,321 (44.6%) had a prolonged QRS duration. During a median follow up of 9.9 months, the all-cause mortality rate was 18.7% for patients with a normal baseline QRS duration and 28.1% for patients with a prolonged baseline QRS.

After adjusting for confounding variables, patients with a prolonged baseline QRS had a 24% increased risk of all-cause mortality and a 28% increased risk for a composite endpoint of cardiac mortality or hospitalization for heart failure exacerbation.

The retrospective nature of the analysis represents the major limitation of this study. In addition, most of the enrolled patients were white, which limits the studies generalizability to other ethnic groups.

Bottom Line: A prolonged QRS duration for patients admitted with decompensated left ventricular heart failure is common and may be associated with increased morbidity and mortality.

Citation: Wang NC, Maggioni AP, Konstam MA, Zannad F, Drasa HB, Burnett JC, et al. Clinical implications of QRS duration in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction. JAMA. 2008;299(22):2656-2666.

For patients with out-of-hospital cardiac arrest, does the addition of vasopressin to epinephrine in a protocol for ACLS improve outcomes?

Background: The outcome for patients experiencing cardiac arrest who require vasopressors remains extremely poor. Despite disappointing data on vasopressin as an alternative treatment during cardiac arrest, a recent subgroup analysis suggested patients who received epinephrine and vasopressin together had superior clinical outcomes.

Study Design: Prospective multicenter randomized double-blind controlled trial.

Setting: 31 emergency medical service organizations in France.

Synopsis: Of the 2,894 patients, 20.7% of those receiving combination treatment (vasopressin plus epinephrine) survived to hospital admission versus 21.3% of those in the epinephrine-only group. For those same groups, 1.7% of combination and 2.3% of epinephrine-only patients survived to hospital discharge. No significant outcome differences were found in any group or subgroup analysis.

The study had lower-than-expected overall survival to hospital discharge, which may have handicapped its effort to find a true difference in treatment arms.

Bottom line: The addition of vasopressin to epinephrine in the treatment of out-of-hospital cardiac arrest does not improve outcomes.

Citation: Gueugniaud PY, David JS, Chanzy E, Hubert H, Dubien P, Mauriaucourt P, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359(1):21-30.

Is oral rivaroxaban more efficacious than subcutaneous enoxaparin in preventing VTE after hip-replacement surgery?

Background: Venous thromboembolism (VTE) prophylaxis after total hip replacement (THR) is important but can be cumbersome because the most commonly used anticoagulants are either subcutaneous or require frequent monitoring. Rivaroxaban, an oral direct inhibitor of factor Xa may provide more convenient anticoagulation postoperatively. However, its efficacy and safety are unknown.

Study design: Randomized double-blind trial.

Setting: Multicenter study performed in 27 countries.

Synopsis: Patients undergoing THR surgery were randomized to oral rivaroxaban (10mg once daily without monitoring, started six to eight hours after surgery) or subcutaneous enoxaparin (40mg once daily, started 12 hours prior to surgery). After surgery, prophylaxis was administered for 35 days. The primary outcome was a composite of asymptomatic deep venous thrombosis (DVT), symptomatic DVT or pulmonary embolism (PE), or death from any cause at 36 days after surgery.

In the enoxaparin group, 3.7% of patients experienced the primary outcome. This decreased to 1.1% in the rivaroxaban group. Approximately one-third of events were symptomatic. Major bleeding occurred in 0.1% and 0.3% (p=NS) of patients in the enoxaparin and rivaroxaban groups, respectively.

The study is limited by the exclusion of 1,388 of the 4,541 patients (30.6%) randomized, primarily due to having inadequate venography. Also, because the majority of thromboembolic events were asymptomatic, the primary outcome overemphasizes the clinical difference.

Bottom line: Oral rivaroxaban without monitoring is more efficacious than, and as safe as, subcutaneous enoxaparin when used for VTE prophylaxis for THR.

Citation: Eriksson B, Borris LC, Friedman RJ, Hass S, Huisman MV, Kakkar AK, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358:2765-75.

Is LMWH more efficacious than UFH in preventing postoperative VTE in cancer patients?

Background: Patients with cancer are at increased risk for VTE and require prophylaxis to prevent this complication postoperatively. Low molecular weight heparin (LMWH) has proven more efficacious than subcutaneous unfractionated heparin (UFH) in other settings (e.g., DVT treatment). However, it is still unknown whether LMWH offers better prophylaxis compared to UFH for cancer patients undergoing surgery.

Study design: Systematic review and meta-analysis.

Setting: 14 randomized controlled trials.

Synopsis: Eleven trials exclusively examined patients with cancer (n=4006) and three trials reported data for cancer patients as subgroups (n=1816). There were in differences in mortality, pulmonary embolism, and symptomatic DVT rates between the two groups.

LMWH was associated with a decrease in total (asymptomatic or symptomatic) DVT (RR, 0.72; 95% CI, 0.55-0.94). Rates of major bleeding, minor bleeding, and intraoperative blood loss were similar between the two treatments.

This meta-analysis is limited because 12 remaining trials (n=3185) also enrolled cancer patients but did not provide specific data for the cancer patient subgroup. The study also is limited by the heterogeneity of the original trials, including utilizing varying LMWHs and dosing regimens, numerous types of surgeries, and a wide range of neoplasms.

Bottom line: LMWH does not decrease mortality, pulmonary embolism, or symptomatic DVT compared to UFH in cancer patients undergoing surgery.

Citation: Akl EA, Terrenato I, Barba M, Sperati F, Sempos EV, Muti P, et al. Low-molecular-weight heparin vs. unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Arch Intern Med. 2008;168:1261-9.

Does salmeterol added to inhaled corticosteroids improve severe asthma-related events?

Background: Asthma is a chronic disease causing major morbidity and mortality worldwide. Disease guidelines recommend all patients with persistent asthma be treated with inhaled corticosteroids. These same guidelines recommend adding a long-acting beta-agonist for patients whose symptoms persist. However, the safety of this practice has come under scrutiny.

Study design: Meta-analysis.

Setting: Sixty-six randomized, controlled trials conducted worldwide.

Synopsis: Analysis included 66 GlaxoSmithKline trials with a total of 20,966 patients with persistent asthma. Patients used either salmeterol (50mcg twice daily) plus inhaled corticosteroid (10,400 patients) or inhaled corticosteroid alone (10,566 patients).

Results showed no differences in asthma-related hospitalizations, asthma-related intubations, or deaths between the two groups. However, due to the low number of events, definitive conclusions are difficult to make. Severe asthma exacerbations requiring systemic corticosteroids significantly decreased in the inhaled corticosteroid plus salmeterol group.

The study is limited by it inclusion of only those trials sponsored by GlaxoSmithKline and by the short duration of most of the studies. Additionally, the studies included in the analysis used clinical outcomes as secondary endpoints.

Bottom line: Adding salmeterol to inhaled corticosteroid decreases severe asthma exacerbations and is likely safe, but does not have an effect on asthma-related hospitalization or death.

Citation: Bateman E, Nelson H, Bousquet J, Kral K, Sutton L, Ortega H, et.al. Meta-analysis: Effects of adding salmeterol to inhaled corticosteroids on serious asthma-related events. Annals Intern Med. 2008;149:33-42.

Is an early invasive strategy effective in women with unstable angina or NSTEMI?

Background: Despite many trials showing the value of an early invasive strategy for patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS), data from several trials question this benefit in women. Some trials show higher risk of death and myocardial infarction (MI) in subgroup analysis of women.

Study Design: Meta-analysis.

Setting: Eight randomized, controlled trials conducted worldwide.

Synopsis: Analysis included eight trials with 10,412 patients (3,075 women) with NSTE ACS. The invasive group (5,083 patients) was defined as those referred for coronary angiography with subsequent intervention as needed. The composite endpoint of death, MI, or rehospitalization within 12 months with ACS occurred in 21.1% of the invasive group and 25.9% of the medically managed group (OR, 0.78; CI, 0.61-0.98).

The subgroup, including only women, had a non-statistically significant OR of 0.81 (CI, 0.65-1.01), including no effect on all-cause mortality, nonfatal MI, or the composite of death and MI. However, women with high-risk features (elevated biomarkers) undergoing the invasive strategy had a significant reduction in the composite endpoint (OR, 0.67; CI, 0.50-0.88).

The study is limited by the use of subgroup analysis, secondary endpoints, heterogeneity between trials, and possible publication bias.

Bottom line: Early invasive strategy is effective in men and high-risk women with NSTE ACS, but not in low-risk women.

Citation: O’Donoghue M, Boden W, Braunwald E, Cannon CP, Clayton TC, Winter RJ, et.al. Early invasive vs. conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction. JAMA. 2008;300:71-80.

What strategies are used to prevent contrast-induced acute kidney injury?

Background: Contrast-induced acute kidney injury (CIAKI) is a condition potentially amenable to preventive care. Several trials have identified intravenous hydration, N-acetylcysteine, and withdrawal of NSAIDS as interventions that reduce the possibility of CIAKI in high-risk patients. Little is known about whether healthcare providers routinely use these strategies.

Study design: Prospective observational cohort study.

Setting: Veterans Affairs (VA) Pittsburgh Healthcare System.

Synopsis: 11,410 patients scheduled for radiographic procedures were screened. After exclusion criteria and eligibility, 660 patients with an estimated glomerular filtration rate less than 60ml/min/1.73m2 were identified. Usage of intravenous fluids, N-acetylcysteine, and discontinuation of NSAIDS were recorded. Serum creatinine (SCr) was measured 48 to 96 hours post-procedure. CIAKI was defined as relative increase in SCr from baseline (≥25%, ≥50% and ≥100%) and absolute increase in SCr levels from baseline (≥0.25, ≥0.5, and ≥1.0). CIAKI association with adverse outcomes was evaluated by tracking 30-day mortality, need for dialysis, and hospitalization.

The incidence of CIAKI was less common in patients undergoing CT scans versus those having angiograms. Adverse 30-day outcomes were uncommon. Pre- and post-procedure intravenous hydration was administered to 40% of study patients, more commonly with coronary angiogram than with computed tomography (91.2% vs. 16%, p<0.0001). N-acetylcysteine was administered to 39.2%. Only 6.8% of those taking NSAIDS reported being told to discontinue the medication.

Study limitations include the small sample size and the single site location, both limiting generalizability.

Bottom line: Clinically significant CIAKI is uncommon, and preventive care is not uniformly implemented in patients undergoing contrast-enhanced radiographic procedures.

Citation: Weisbord SD, Mor MK, Resnick AL, Hartwig KC, Sonel AF, Fine MJ, et al. Prevention, incidence, and outcomes of contrast-induced acute kidney injury. Arch Intern Med. 2008;168(12):1325-1332.

How does hyperglycemia affect morbidity and mortality in children admitted to a community pediatric hospital?

Background: Inpatient hyperglycemia in adult patients is a predictor of poor clinical outcomes. The association of hyperglycemia and clinical outcomes in children admitted to a general community hospital has not been studied.

Study design: Retrospective observational cohort study.

Setting: A community pediatric hospital in Atlanta, Ga.

Synopsis: Review of medical records of 903 consecutive pediatric patients admitted to critical and non-critical areas took place. Of these, 542 patients constituted the study population. The study excluded 342 patients who didn’t have a blood glucose measurement. Hyperglycemia was defined as an admission or in-hospital blood glucose greater than 120mg/dl.

One-fourth of the children admitted to the hospital had hyperglycemia, most without a prior history of diabetes. The presence of hyperglycemia on admission was not associated with increased length of stay (LOS) or increased mortality. Children with hyperglycemia were more likely to be admitted to the ICU and had longer ICU LOS.

This was a retrospective study conducted at a single site whose demographics and disease spectrum may differ from those of other institutions. There were an insufficient number of deaths to make any conclusions regarding the impact of hyperglycemia on mortality. Prospective, randomized, multicenter trials are needed to better elucidate the effects of in-patient hyperglycemia.

Bottom line: Hyperglycemia is common in children with or without diabetes admitted to the hospital, and is associated with increased ICU admissions and ICU length of stay. Its connection to mortality is inconclusive.

Citation: Palaio A, Smiley D, Ceron M, Klein R, Cho IS, Mejia R, et al. Prevalence and clinical outcome of inpatient hyperglycemia in a community pediatric hospital. J Hosp Med.2008;3(3):212-217.

Literature at a Glance

• Drug-eluting stents decrease the need for revascularization.
• Case volume is related to hospital performance assessment.
• Prolonged QRS duration in patients with CHF is associated with increased morbidity and mortality.
• For out-of-hospital ACLS, vasopressin plus epinephrine is not better than vasopressin alone.
• Oral rivaroxaban is more efficacious than enoxaparin for VTE prophylaxis after total hip replacement.
• LMWH and UFH offer similar perioperative VTE prophylaxis benefit in patients with cancer.
• Salmeterol added to inhaled corticosteroids decreases severe asthma exacerbations.
• Early invasive strategy has unclear benefit in low-risk women with unstable angina or NSTEMI.
• Strategies to prevent contrast-induced acute kidney injury are not uniform.
• Hyperglycemia in hospitalized children is common and associated with ICU admission.

Do drug-eluting stents improve outcomes after ST-elevation myocardial infarction (STEMI)?

Background: Drug-eluting stents reduce restenosis rates compared to bare-metal stents. However, there is concern drug-eluting stents increase the risk of stent thrombosis leading to MI and death. Prior studies compared patients who received bare-metal versus those who received drug-eluting stents. Outcomes on a population level might provide new insight.

Study design: Observational study.

Setting: 100% national sample of patients 65 and older who received a coronary stent from 2002-05 enrolled in the traditional fee-for-service Medicare program.

Synopsis: 38,917 patients in the pre-drug-eluting-stent era from October 2002 to March 2003 received bare-metal stents. Nearly 62% of 28,086 patients studied from September to December 2003 received drug-eluting stents. The remaining 38.5% received bare-metal stents. Outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), STEMI, and death were observed through December 31, 2005.

Patients in the drug-eluting-stent era had a lower two-year risk for repeat revascularization compared to patients in the bare-metal-stent era. In the drug-eluting versus bare-metal eras, repeat PCI was 17.1% versus 20.0% (p<0.001) and need for CABG was 2.7% versus 4.2% (p<0.01). Comparing adjusted outcomes for death, or STEMI, at two years, the two groups appeared similar.

The study did have limitations: the data only reflect sirolimus stents, the authors could not assess dual-antiplatelet therapy or obtain information on coronary anatomy or procedure details to account for selection bias in stent utilization, and the patients were all Medicare beneficiaries.

Bottom line: Drug-eluting stents are associated with fewer repeat revascularization procedures than bare-metal stents, but have not shown a significant improvement in the subsequent risk of STEMI or death.

Citation: Malenka DJ, Kaplan AV, Lucas FL, Sharp SM, Skinner JA. Outcomes following coronary stenting in the era of bare-metal vs. the era of drug-eluting stents. JAMA 2008;299(24):2868-2877.

Does case volume affect hospital performance for publicly reported process measures?

Background: Hospitals are increasingly graded and compared to one another. “Top medical centers” are defined as those within the top 10% of hospitals in specified performance measures. Hospitals with large and small case volumes might not be compared evenly and fairly.

Study design: Eight publicly reported process measures for acute myocardial infarction (AMI) were compared to hospital case volume, process performance, and label as “top hospital.”

Setting: Data were analyzed from the Hospital Quality Alliance for 3,761 hospitals from January to December 2005.

Synopsis: Hospitals with large case volume overall had better process performance. For example, looking at use of beta-blockers in patients with AMI on arrival to a hospital, small-volume hospitals (<10 AMI cases) averaged 72% while large volume (>100 AMI cases) averaged 80% (p<0.001). However, hospitals with small case volumes were more likely to receive “top hospital” rating even when hospitals with very low case volumes were excluded.

Hospital quality reporting that does not account for case volume is misleading to hospitals and consumers. In this study, larger-volume hospitals appeared to perform better in process measures, but were less likely to receive “top hospital” rating.

Bottom line: Hospitals with large and small case volumes can easily be compared to one another for process measures in AMI.

Citation: O’Brien SM, DeLong ER, Peterson ED. Impact of case volume on hospital performance assessment. Arch Intern Med. 2008;168(12):1277-1284.

What is the predictive value of QRS duration in patients hospitalized with worsening CHF?

Background: In outpatients, a prolonged QRS duration (greater than 120 ms) is associated with increased mortality. Its value in the inpatient setting is unclear. For patients hospitalized with CHF exacerbations, establishing the value of QRS duration may allow for tailored management.

Study design: Retrospective post hoc analysis from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST).

Setting: 4,133 patients were enrolled from North American, South American, and European sites.

Synopsis: Of 2,962 patients included in the final post hoc analysis, 1,321 (44.6%) had a prolonged QRS duration. During a median follow up of 9.9 months, the all-cause mortality rate was 18.7% for patients with a normal baseline QRS duration and 28.1% for patients with a prolonged baseline QRS.

After adjusting for confounding variables, patients with a prolonged baseline QRS had a 24% increased risk of all-cause mortality and a 28% increased risk for a composite endpoint of cardiac mortality or hospitalization for heart failure exacerbation.

The retrospective nature of the analysis represents the major limitation of this study. In addition, most of the enrolled patients were white, which limits the studies generalizability to other ethnic groups.

Bottom Line: A prolonged QRS duration for patients admitted with decompensated left ventricular heart failure is common and may be associated with increased morbidity and mortality.

Citation: Wang NC, Maggioni AP, Konstam MA, Zannad F, Drasa HB, Burnett JC, et al. Clinical implications of QRS duration in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction. JAMA. 2008;299(22):2656-2666.

For patients with out-of-hospital cardiac arrest, does the addition of vasopressin to epinephrine in a protocol for ACLS improve outcomes?

Background: The outcome for patients experiencing cardiac arrest who require vasopressors remains extremely poor. Despite disappointing data on vasopressin as an alternative treatment during cardiac arrest, a recent subgroup analysis suggested patients who received epinephrine and vasopressin together had superior clinical outcomes.

Study Design: Prospective multicenter randomized double-blind controlled trial.

Setting: 31 emergency medical service organizations in France.

Synopsis: Of the 2,894 patients, 20.7% of those receiving combination treatment (vasopressin plus epinephrine) survived to hospital admission versus 21.3% of those in the epinephrine-only group. For those same groups, 1.7% of combination and 2.3% of epinephrine-only patients survived to hospital discharge. No significant outcome differences were found in any group or subgroup analysis.

The study had lower-than-expected overall survival to hospital discharge, which may have handicapped its effort to find a true difference in treatment arms.

Bottom line: The addition of vasopressin to epinephrine in the treatment of out-of-hospital cardiac arrest does not improve outcomes.

Citation: Gueugniaud PY, David JS, Chanzy E, Hubert H, Dubien P, Mauriaucourt P, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359(1):21-30.

Is oral rivaroxaban more efficacious than subcutaneous enoxaparin in preventing VTE after hip-replacement surgery?

Background: Venous thromboembolism (VTE) prophylaxis after total hip replacement (THR) is important but can be cumbersome because the most commonly used anticoagulants are either subcutaneous or require frequent monitoring. Rivaroxaban, an oral direct inhibitor of factor Xa may provide more convenient anticoagulation postoperatively. However, its efficacy and safety are unknown.

Study design: Randomized double-blind trial.

Setting: Multicenter study performed in 27 countries.

Synopsis: Patients undergoing THR surgery were randomized to oral rivaroxaban (10mg once daily without monitoring, started six to eight hours after surgery) or subcutaneous enoxaparin (40mg once daily, started 12 hours prior to surgery). After surgery, prophylaxis was administered for 35 days. The primary outcome was a composite of asymptomatic deep venous thrombosis (DVT), symptomatic DVT or pulmonary embolism (PE), or death from any cause at 36 days after surgery.

In the enoxaparin group, 3.7% of patients experienced the primary outcome. This decreased to 1.1% in the rivaroxaban group. Approximately one-third of events were symptomatic. Major bleeding occurred in 0.1% and 0.3% (p=NS) of patients in the enoxaparin and rivaroxaban groups, respectively.

The study is limited by the exclusion of 1,388 of the 4,541 patients (30.6%) randomized, primarily due to having inadequate venography. Also, because the majority of thromboembolic events were asymptomatic, the primary outcome overemphasizes the clinical difference.

Bottom line: Oral rivaroxaban without monitoring is more efficacious than, and as safe as, subcutaneous enoxaparin when used for VTE prophylaxis for THR.

Citation: Eriksson B, Borris LC, Friedman RJ, Hass S, Huisman MV, Kakkar AK, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358:2765-75.

Is LMWH more efficacious than UFH in preventing postoperative VTE in cancer patients?

Background: Patients with cancer are at increased risk for VTE and require prophylaxis to prevent this complication postoperatively. Low molecular weight heparin (LMWH) has proven more efficacious than subcutaneous unfractionated heparin (UFH) in other settings (e.g., DVT treatment). However, it is still unknown whether LMWH offers better prophylaxis compared to UFH for cancer patients undergoing surgery.

Study design: Systematic review and meta-analysis.

Setting: 14 randomized controlled trials.

Synopsis: Eleven trials exclusively examined patients with cancer (n=4006) and three trials reported data for cancer patients as subgroups (n=1816). There were in differences in mortality, pulmonary embolism, and symptomatic DVT rates between the two groups.

LMWH was associated with a decrease in total (asymptomatic or symptomatic) DVT (RR, 0.72; 95% CI, 0.55-0.94). Rates of major bleeding, minor bleeding, and intraoperative blood loss were similar between the two treatments.

This meta-analysis is limited because 12 remaining trials (n=3185) also enrolled cancer patients but did not provide specific data for the cancer patient subgroup. The study also is limited by the heterogeneity of the original trials, including utilizing varying LMWHs and dosing regimens, numerous types of surgeries, and a wide range of neoplasms.

Bottom line: LMWH does not decrease mortality, pulmonary embolism, or symptomatic DVT compared to UFH in cancer patients undergoing surgery.

Citation: Akl EA, Terrenato I, Barba M, Sperati F, Sempos EV, Muti P, et al. Low-molecular-weight heparin vs. unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Arch Intern Med. 2008;168:1261-9.

Does salmeterol added to inhaled corticosteroids improve severe asthma-related events?

Background: Asthma is a chronic disease causing major morbidity and mortality worldwide. Disease guidelines recommend all patients with persistent asthma be treated with inhaled corticosteroids. These same guidelines recommend adding a long-acting beta-agonist for patients whose symptoms persist. However, the safety of this practice has come under scrutiny.

Study design: Meta-analysis.

Setting: Sixty-six randomized, controlled trials conducted worldwide.

Synopsis: Analysis included 66 GlaxoSmithKline trials with a total of 20,966 patients with persistent asthma. Patients used either salmeterol (50mcg twice daily) plus inhaled corticosteroid (10,400 patients) or inhaled corticosteroid alone (10,566 patients).

Results showed no differences in asthma-related hospitalizations, asthma-related intubations, or deaths between the two groups. However, due to the low number of events, definitive conclusions are difficult to make. Severe asthma exacerbations requiring systemic corticosteroids significantly decreased in the inhaled corticosteroid plus salmeterol group.

The study is limited by it inclusion of only those trials sponsored by GlaxoSmithKline and by the short duration of most of the studies. Additionally, the studies included in the analysis used clinical outcomes as secondary endpoints.

Bottom line: Adding salmeterol to inhaled corticosteroid decreases severe asthma exacerbations and is likely safe, but does not have an effect on asthma-related hospitalization or death.

Citation: Bateman E, Nelson H, Bousquet J, Kral K, Sutton L, Ortega H, et.al. Meta-analysis: Effects of adding salmeterol to inhaled corticosteroids on serious asthma-related events. Annals Intern Med. 2008;149:33-42.

Is an early invasive strategy effective in women with unstable angina or NSTEMI?

Background: Despite many trials showing the value of an early invasive strategy for patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS), data from several trials question this benefit in women. Some trials show higher risk of death and myocardial infarction (MI) in subgroup analysis of women.

Study Design: Meta-analysis.

Setting: Eight randomized, controlled trials conducted worldwide.

Synopsis: Analysis included eight trials with 10,412 patients (3,075 women) with NSTE ACS. The invasive group (5,083 patients) was defined as those referred for coronary angiography with subsequent intervention as needed. The composite endpoint of death, MI, or rehospitalization within 12 months with ACS occurred in 21.1% of the invasive group and 25.9% of the medically managed group (OR, 0.78; CI, 0.61-0.98).

The subgroup, including only women, had a non-statistically significant OR of 0.81 (CI, 0.65-1.01), including no effect on all-cause mortality, nonfatal MI, or the composite of death and MI. However, women with high-risk features (elevated biomarkers) undergoing the invasive strategy had a significant reduction in the composite endpoint (OR, 0.67; CI, 0.50-0.88).

The study is limited by the use of subgroup analysis, secondary endpoints, heterogeneity between trials, and possible publication bias.

Bottom line: Early invasive strategy is effective in men and high-risk women with NSTE ACS, but not in low-risk women.

Citation: O’Donoghue M, Boden W, Braunwald E, Cannon CP, Clayton TC, Winter RJ, et.al. Early invasive vs. conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction. JAMA. 2008;300:71-80.

What strategies are used to prevent contrast-induced acute kidney injury?

Background: Contrast-induced acute kidney injury (CIAKI) is a condition potentially amenable to preventive care. Several trials have identified intravenous hydration, N-acetylcysteine, and withdrawal of NSAIDS as interventions that reduce the possibility of CIAKI in high-risk patients. Little is known about whether healthcare providers routinely use these strategies.

Study design: Prospective observational cohort study.

Setting: Veterans Affairs (VA) Pittsburgh Healthcare System.

Synopsis: 11,410 patients scheduled for radiographic procedures were screened. After exclusion criteria and eligibility, 660 patients with an estimated glomerular filtration rate less than 60ml/min/1.73m2 were identified. Usage of intravenous fluids, N-acetylcysteine, and discontinuation of NSAIDS were recorded. Serum creatinine (SCr) was measured 48 to 96 hours post-procedure. CIAKI was defined as relative increase in SCr from baseline (≥25%, ≥50% and ≥100%) and absolute increase in SCr levels from baseline (≥0.25, ≥0.5, and ≥1.0). CIAKI association with adverse outcomes was evaluated by tracking 30-day mortality, need for dialysis, and hospitalization.

The incidence of CIAKI was less common in patients undergoing CT scans versus those having angiograms. Adverse 30-day outcomes were uncommon. Pre- and post-procedure intravenous hydration was administered to 40% of study patients, more commonly with coronary angiogram than with computed tomography (91.2% vs. 16%, p<0.0001). N-acetylcysteine was administered to 39.2%. Only 6.8% of those taking NSAIDS reported being told to discontinue the medication.

Study limitations include the small sample size and the single site location, both limiting generalizability.

Bottom line: Clinically significant CIAKI is uncommon, and preventive care is not uniformly implemented in patients undergoing contrast-enhanced radiographic procedures.

Citation: Weisbord SD, Mor MK, Resnick AL, Hartwig KC, Sonel AF, Fine MJ, et al. Prevention, incidence, and outcomes of contrast-induced acute kidney injury. Arch Intern Med. 2008;168(12):1325-1332.

How does hyperglycemia affect morbidity and mortality in children admitted to a community pediatric hospital?

Background: Inpatient hyperglycemia in adult patients is a predictor of poor clinical outcomes. The association of hyperglycemia and clinical outcomes in children admitted to a general community hospital has not been studied.

Study design: Retrospective observational cohort study.

Setting: A community pediatric hospital in Atlanta, Ga.

Synopsis: Review of medical records of 903 consecutive pediatric patients admitted to critical and non-critical areas took place. Of these, 542 patients constituted the study population. The study excluded 342 patients who didn’t have a blood glucose measurement. Hyperglycemia was defined as an admission or in-hospital blood glucose greater than 120mg/dl.

One-fourth of the children admitted to the hospital had hyperglycemia, most without a prior history of diabetes. The presence of hyperglycemia on admission was not associated with increased length of stay (LOS) or increased mortality. Children with hyperglycemia were more likely to be admitted to the ICU and had longer ICU LOS.

This was a retrospective study conducted at a single site whose demographics and disease spectrum may differ from those of other institutions. There were an insufficient number of deaths to make any conclusions regarding the impact of hyperglycemia on mortality. Prospective, randomized, multicenter trials are needed to better elucidate the effects of in-patient hyperglycemia.

Bottom line: Hyperglycemia is common in children with or without diabetes admitted to the hospital, and is associated with increased ICU admissions and ICU length of stay. Its connection to mortality is inconclusive.

Citation: Palaio A, Smiley D, Ceron M, Klein R, Cho IS, Mejia R, et al. Prevalence and clinical outcome of inpatient hyperglycemia in a community pediatric hospital. J Hosp Med.2008;3(3):212-217.

Within the next few months, many of you will have a new job as an attending hospitalist. As daunting as that may seem, now is the time to think about what you can do to ensure a smooth transition and successful beginning to your career.

Although residency prepared you to face the medical challenges ahead, here are 10 pointers that may help as you move to the next stage of your professional life.

1) Familiarize yourself with the licensing/credentialing process: Do not underestimate the amount of time it takes to get this paperwork approved—up to six months in some cases. Many new hires’ first days on the job are delayed because they didn’t complete this step. Check with state licensing boards for special requirements unique to that state. Also, every hospital has its own gauntlet of infectious disease, HIPAA, and information- technology hoops to jump through. Getting your applications in as early as possible puts you in position to begin on your planned start date and prevent last-minute catastrophes for your new program.

2) Gain valuable insight through observation: Study your current hospitalist group to gain perspective that will help in your new setting. All programs and hospitals operate differently and have room for quality/process improvement. Interview hospitalists, ask questions, and observe the workflow in your current hospital(s) to help in your new job.

3) Contemplate your career direction: Think strategically about your strengths and plans. Although you will learn an incredible amount about hospital medicine careers after you begin, having a sense of direction will help your new group and its leadership get you where you want to be. Making connections and making your goals known within your new program before you start will put your new career on the right path.

4) Seek mentors: Having mentors from your prior program and your new program is a key to a healthy and happy career. Choose people you respect and pick their brains about their careers, how they acquired their skills, and how they would advise you to do the same. Good mentors will help you for many years, and the most valuable may be the ones who have known you throughout your residency. Nurture and maintain these relationships even if you are moving on to new horizons. Inquire whether your new program has a mentorship structure or if your new group leader can recommend someone who shares common interests and goals.

5) Study SHM’s Core Com-petencies: Although you may have trepidation about your medical skills and knowledge as you move into uncharted waters, step back and relax. Know that you are prepared. That said, you can always learn more. One excellent resource is The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available on SHM’s Web site, www.hospitalmedicine.org). This is a set of standards with which programs can teach hospital medicine and you can learn the scope of expectations and competencies for someone in your position.

6) Understand the nuts and bolts of your new program: Although there are many things you will learn on the job, gain an appreciation for some of the following before your first day:

• Billing: If this is your responsibility, you need to learn a little about this before you start, preferably from one of your future colleagues.
• Reimbursement structure: Find out how your productivity is tracked and rewarded. You’d be amazed how variable this can be.
• Time allotment: How are administrative, research, committee and teaching time balanced against your clinical time?

7) Get to know your new hospital: Before hitting the wards it pays to do a little homework on your new workplace. Do you have access to a medical library, journals, UpToDate, or other online databases? If not, do you need to purchase this access on your own? Many programs have academic funds allotted so you can use those resources. Also, familiarize yourself with the local antibiogram, formularies, guidelines, and order sets. Most facilities have tools specific to their hospital. Know how these affect you in your new role. Prior to starting, you will also want to be sufficiently oriented to any computer systems and understand how they’re used for documentation and order entry, and for viewing lab, radiology, and microbiology results.

8) Shadow a hospitalist: Spending a few hours with someone during a typical hospitalist work day will give you an idea of the pace of the work, the layout of the hospital and floors, the medical and ancillary staff you will work with, and the patient population. This will prompt questions you hadn’t thought of previously.

9) Prepare for each specific role: Hospitalists wear many hats, including teaching attending, non-teaching attending, consultant, researcher, committee member, and hospital medicine leader. Each role carries specific responsibilities and expectations. Prior to each new role, train with someone who leads that service or knows the job intimately.

10) Comprehend your benefits: Does your employer have a retirement program? Do they match retirement contributions? How does the malpractice insurance work? A meeting with human resources will usually help you arrange your health, dental, malpractice, and disability insurance prior to your start date. TH

Dr. Chacko is chair of SHM’s young physician committee and the hospitalist program medical director for Preferred Health Partners in New York City. Dr. Markoff is an assistant professor of medicine and associate director of the hospitalist service at the Mount Sinai Hospital in New York City. Dr. Sliwka is a hospitalist and assistant professor of clinical medicine at the University of California, San Francisco Medical Center.

Within the next few months, many of you will have a new job as an attending hospitalist. As daunting as that may seem, now is the time to think about what you can do to ensure a smooth transition and successful beginning to your career.

Although residency prepared you to face the medical challenges ahead, here are 10 pointers that may help as you move to the next stage of your professional life.

1) Familiarize yourself with the licensing/credentialing process: Do not underestimate the amount of time it takes to get this paperwork approved—up to six months in some cases. Many new hires’ first days on the job are delayed because they didn’t complete this step. Check with state licensing boards for special requirements unique to that state. Also, every hospital has its own gauntlet of infectious disease, HIPAA, and information- technology hoops to jump through. Getting your applications in as early as possible puts you in position to begin on your planned start date and prevent last-minute catastrophes for your new program.

2) Gain valuable insight through observation: Study your current hospitalist group to gain perspective that will help in your new setting. All programs and hospitals operate differently and have room for quality/process improvement. Interview hospitalists, ask questions, and observe the workflow in your current hospital(s) to help in your new job.

3) Contemplate your career direction: Think strategically about your strengths and plans. Although you will learn an incredible amount about hospital medicine careers after you begin, having a sense of direction will help your new group and its leadership get you where you want to be. Making connections and making your goals known within your new program before you start will put your new career on the right path.

4) Seek mentors: Having mentors from your prior program and your new program is a key to a healthy and happy career. Choose people you respect and pick their brains about their careers, how they acquired their skills, and how they would advise you to do the same. Good mentors will help you for many years, and the most valuable may be the ones who have known you throughout your residency. Nurture and maintain these relationships even if you are moving on to new horizons. Inquire whether your new program has a mentorship structure or if your new group leader can recommend someone who shares common interests and goals.

5) Study SHM’s Core Com-petencies: Although you may have trepidation about your medical skills and knowledge as you move into uncharted waters, step back and relax. Know that you are prepared. That said, you can always learn more. One excellent resource is The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available on SHM’s Web site, www.hospitalmedicine.org). This is a set of standards with which programs can teach hospital medicine and you can learn the scope of expectations and competencies for someone in your position.

6) Understand the nuts and bolts of your new program: Although there are many things you will learn on the job, gain an appreciation for some of the following before your first day:

• Billing: If this is your responsibility, you need to learn a little about this before you start, preferably from one of your future colleagues.
• Reimbursement structure: Find out how your productivity is tracked and rewarded. You’d be amazed how variable this can be.
• Time allotment: How are administrative, research, committee and teaching time balanced against your clinical time?

7) Get to know your new hospital: Before hitting the wards it pays to do a little homework on your new workplace. Do you have access to a medical library, journals, UpToDate, or other online databases? If not, do you need to purchase this access on your own? Many programs have academic funds allotted so you can use those resources. Also, familiarize yourself with the local antibiogram, formularies, guidelines, and order sets. Most facilities have tools specific to their hospital. Know how these affect you in your new role. Prior to starting, you will also want to be sufficiently oriented to any computer systems and understand how they’re used for documentation and order entry, and for viewing lab, radiology, and microbiology results.

8) Shadow a hospitalist: Spending a few hours with someone during a typical hospitalist work day will give you an idea of the pace of the work, the layout of the hospital and floors, the medical and ancillary staff you will work with, and the patient population. This will prompt questions you hadn’t thought of previously.

9) Prepare for each specific role: Hospitalists wear many hats, including teaching attending, non-teaching attending, consultant, researcher, committee member, and hospital medicine leader. Each role carries specific responsibilities and expectations. Prior to each new role, train with someone who leads that service or knows the job intimately.

10) Comprehend your benefits: Does your employer have a retirement program? Do they match retirement contributions? How does the malpractice insurance work? A meeting with human resources will usually help you arrange your health, dental, malpractice, and disability insurance prior to your start date. TH

Dr. Chacko is chair of SHM’s young physician committee and the hospitalist program medical director for Preferred Health Partners in New York City. Dr. Markoff is an assistant professor of medicine and associate director of the hospitalist service at the Mount Sinai Hospital in New York City. Dr. Sliwka is a hospitalist and assistant professor of clinical medicine at the University of California, San Francisco Medical Center.

Within the next few months, many of you will have a new job as an attending hospitalist. As daunting as that may seem, now is the time to think about what you can do to ensure a smooth transition and successful beginning to your career.

Although residency prepared you to face the medical challenges ahead, here are 10 pointers that may help as you move to the next stage of your professional life.

1) Familiarize yourself with the licensing/credentialing process: Do not underestimate the amount of time it takes to get this paperwork approved—up to six months in some cases. Many new hires’ first days on the job are delayed because they didn’t complete this step. Check with state licensing boards for special requirements unique to that state. Also, every hospital has its own gauntlet of infectious disease, HIPAA, and information- technology hoops to jump through. Getting your applications in as early as possible puts you in position to begin on your planned start date and prevent last-minute catastrophes for your new program.

2) Gain valuable insight through observation: Study your current hospitalist group to gain perspective that will help in your new setting. All programs and hospitals operate differently and have room for quality/process improvement. Interview hospitalists, ask questions, and observe the workflow in your current hospital(s) to help in your new job.

3) Contemplate your career direction: Think strategically about your strengths and plans. Although you will learn an incredible amount about hospital medicine careers after you begin, having a sense of direction will help your new group and its leadership get you where you want to be. Making connections and making your goals known within your new program before you start will put your new career on the right path.

4) Seek mentors: Having mentors from your prior program and your new program is a key to a healthy and happy career. Choose people you respect and pick their brains about their careers, how they acquired their skills, and how they would advise you to do the same. Good mentors will help you for many years, and the most valuable may be the ones who have known you throughout your residency. Nurture and maintain these relationships even if you are moving on to new horizons. Inquire whether your new program has a mentorship structure or if your new group leader can recommend someone who shares common interests and goals.

5) Study SHM’s Core Com-petencies: Although you may have trepidation about your medical skills and knowledge as you move into uncharted waters, step back and relax. Know that you are prepared. That said, you can always learn more. One excellent resource is The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available on SHM’s Web site, www.hospitalmedicine.org). This is a set of standards with which programs can teach hospital medicine and you can learn the scope of expectations and competencies for someone in your position.

6) Understand the nuts and bolts of your new program: Although there are many things you will learn on the job, gain an appreciation for some of the following before your first day:

• Billing: If this is your responsibility, you need to learn a little about this before you start, preferably from one of your future colleagues.
• Reimbursement structure: Find out how your productivity is tracked and rewarded. You’d be amazed how variable this can be.
• Time allotment: How are administrative, research, committee and teaching time balanced against your clinical time?

7) Get to know your new hospital: Before hitting the wards it pays to do a little homework on your new workplace. Do you have access to a medical library, journals, UpToDate, or other online databases? If not, do you need to purchase this access on your own? Many programs have academic funds allotted so you can use those resources. Also, familiarize yourself with the local antibiogram, formularies, guidelines, and order sets. Most facilities have tools specific to their hospital. Know how these affect you in your new role. Prior to starting, you will also want to be sufficiently oriented to any computer systems and understand how they’re used for documentation and order entry, and for viewing lab, radiology, and microbiology results.

8) Shadow a hospitalist: Spending a few hours with someone during a typical hospitalist work day will give you an idea of the pace of the work, the layout of the hospital and floors, the medical and ancillary staff you will work with, and the patient population. This will prompt questions you hadn’t thought of previously.

9) Prepare for each specific role: Hospitalists wear many hats, including teaching attending, non-teaching attending, consultant, researcher, committee member, and hospital medicine leader. Each role carries specific responsibilities and expectations. Prior to each new role, train with someone who leads that service or knows the job intimately.

10) Comprehend your benefits: Does your employer have a retirement program? Do they match retirement contributions? How does the malpractice insurance work? A meeting with human resources will usually help you arrange your health, dental, malpractice, and disability insurance prior to your start date. TH

Dr. Chacko is chair of SHM’s young physician committee and the hospitalist program medical director for Preferred Health Partners in New York City. Dr. Markoff is an assistant professor of medicine and associate director of the hospitalist service at the Mount Sinai Hospital in New York City. Dr. Sliwka is a hospitalist and assistant professor of clinical medicine at the University of California, San Francisco Medical Center.