Those responsible for teaching hospital medicine to residents and medical students had an unprecedented opportunity to become students for the day and learn from top teachers in the field.

An important new addition to the all-day precourses was the “Teaching Hospitalist Educators (THE) Course: What Clinical Teachers in Hospital Medicine Need to Know.” The session was presented by Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, and Mark Williams, MD, director of the hospital medicine program at Northwestern University’s Feinberg School of Medicine in Chicago.

“This pre-course was developed in response to requests from [SHM’s] Education Committee,” said Sylvia McKean, MD, chair of SHM’s Annual Meeting Committee. “It fold[s] in the best suggestions for hospitalist educators. It’s designed to shift those hospitalists who are responsible for education away from knowledge-only [teaching] and toward a performance-based focus.”

The pre-course used SHM’s The Core Competencies in Hospital Medicine as a framework to provide a competency-based model of physician education, one that emphasizes performance-based competencies such as procedures, practice-based learning, and “people skills.” This model can be adapted to teaching residents and students at the bedside as well as in conference rooms and large lecture halls.

“It went beyond curriculum,” said attendee Kevin O’Leary, MD. “It inspired people to think creatively about their own curriculum at home … it was an enlightened teaching model.”

The more than 85 hospitalist educators who attended the pre-course were asked to start a networking group to be called the SHM Educator Network, which will exchange resources and curriculum.

“The goal is for people to share talking points and generate additional tools,” Dr. Williams said. “There are lots of new faculty” teaching hospital medicine across the country. “They need training and they need resources.”

Those responsible for teaching hospital medicine to residents and medical students had an unprecedented opportunity to become students for the day and learn from top teachers in the field.

An important new addition to the all-day precourses was the “Teaching Hospitalist Educators (THE) Course: What Clinical Teachers in Hospital Medicine Need to Know.” The session was presented by Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, and Mark Williams, MD, director of the hospital medicine program at Northwestern University’s Feinberg School of Medicine in Chicago.

“This pre-course was developed in response to requests from [SHM’s] Education Committee,” said Sylvia McKean, MD, chair of SHM’s Annual Meeting Committee. “It fold[s] in the best suggestions for hospitalist educators. It’s designed to shift those hospitalists who are responsible for education away from knowledge-only [teaching] and toward a performance-based focus.”

The pre-course used SHM’s The Core Competencies in Hospital Medicine as a framework to provide a competency-based model of physician education, one that emphasizes performance-based competencies such as procedures, practice-based learning, and “people skills.” This model can be adapted to teaching residents and students at the bedside as well as in conference rooms and large lecture halls.

“It went beyond curriculum,” said attendee Kevin O’Leary, MD. “It inspired people to think creatively about their own curriculum at home … it was an enlightened teaching model.”

The more than 85 hospitalist educators who attended the pre-course were asked to start a networking group to be called the SHM Educator Network, which will exchange resources and curriculum.

“The goal is for people to share talking points and generate additional tools,” Dr. Williams said. “There are lots of new faculty” teaching hospital medicine across the country. “They need training and they need resources.”

Those responsible for teaching hospital medicine to residents and medical students had an unprecedented opportunity to become students for the day and learn from top teachers in the field.

An important new addition to the all-day precourses was the “Teaching Hospitalist Educators (THE) Course: What Clinical Teachers in Hospital Medicine Need to Know.” The session was presented by Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, and Mark Williams, MD, director of the hospital medicine program at Northwestern University’s Feinberg School of Medicine in Chicago.

“This pre-course was developed in response to requests from [SHM’s] Education Committee,” said Sylvia McKean, MD, chair of SHM’s Annual Meeting Committee. “It fold[s] in the best suggestions for hospitalist educators. It’s designed to shift those hospitalists who are responsible for education away from knowledge-only [teaching] and toward a performance-based focus.”

The pre-course used SHM’s The Core Competencies in Hospital Medicine as a framework to provide a competency-based model of physician education, one that emphasizes performance-based competencies such as procedures, practice-based learning, and “people skills.” This model can be adapted to teaching residents and students at the bedside as well as in conference rooms and large lecture halls.

“It went beyond curriculum,” said attendee Kevin O’Leary, MD. “It inspired people to think creatively about their own curriculum at home … it was an enlightened teaching model.”

The more than 85 hospitalist educators who attended the pre-course were asked to start a networking group to be called the SHM Educator Network, which will exchange resources and curriculum.

“The goal is for people to share talking points and generate additional tools,” Dr. Williams said. “There are lots of new faculty” teaching hospital medicine across the country. “They need training and they need resources.”

Couldn’t make it to a session you wanted to attend? Missed the meeting entirely?

This at-a-glance wrap-up provides some highlights from several key sessions:

Clinical Tracks

Key session: “The How, When and Why of Comanagement” presented by Eric M. Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Key session: “Nosocomial Infections and Resistant Organisms” presented by James Pile, MD, FACP, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Operational Track

Key session: “Designing Compensation and Bonus Plans to Drive Desired Behaviors” presented by Rachel M. George, MD, MBA, Cogent Healthcare, Department of Pediatrics at SUNY Downstate Medical Center, Brooklyn, N.Y.; Winthrop Whitcomb, MD, Mercy Medical Center in Springfield, Mass.; and John Bulger DO, FACOI, FACP, Geisinger Health System in Pennsylvania.

Take-away points: Dr. Whitcomb discussed compensation for community-based hospital medicine programs that reward both an individual’s productivity—based on RVUs, charges or cash—and quality measures met, which will directly improve quality.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Academic Track

Key session: “Keys to a Successful Academic Hospitalist Program” presented by Robert M. Wachter, MD, University of California, San Francisco; Brian P. Lucas, MD, MS, Cook County Hospital, Chicago; and Adrienne L. Bennett, MD, PhD, Ohio State University Medical Center, Columbus.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Quality Track

Key session: “Improving Quality and Safety during Transitions of Care” presented by Eric Coleman, MD, MPH, University of Colorado, Denver; Jeffrey Greenwald, MD, Boston University Medical Campus; Lakshmi Halasyamani, MD, St. Joseph Mercy Medical Center, Ann Arbor, Mich.; and Mark V. Williams, MD, Northwestern University’s Feinberg School of Medicine in Chicago.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Pediatric Track

Key session: “Surveys Say ... Current Reports on Pediatric Hospitalist Workload and Compensation” presented by Jack Percelay, MD, MPH, FAAP, ELMO Pediatrics, Livingston, N.J., and David Zipes, MD, FAAP, St. Vincent Children’s Hospital, Indianapolis, Ind.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Key session: “Clinical Pathways on a Budget” presented by Steve Narang, MD, Our Lady of the Lake Regional Medical Center, Baton Rouge, La.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.

Couldn’t make it to a session you wanted to attend? Missed the meeting entirely?

This at-a-glance wrap-up provides some highlights from several key sessions:

Clinical Tracks

Key session: “The How, When and Why of Comanagement” presented by Eric M. Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Key session: “Nosocomial Infections and Resistant Organisms” presented by James Pile, MD, FACP, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Operational Track

Key session: “Designing Compensation and Bonus Plans to Drive Desired Behaviors” presented by Rachel M. George, MD, MBA, Cogent Healthcare, Department of Pediatrics at SUNY Downstate Medical Center, Brooklyn, N.Y.; Winthrop Whitcomb, MD, Mercy Medical Center in Springfield, Mass.; and John Bulger DO, FACOI, FACP, Geisinger Health System in Pennsylvania.

Take-away points: Dr. Whitcomb discussed compensation for community-based hospital medicine programs that reward both an individual’s productivity—based on RVUs, charges or cash—and quality measures met, which will directly improve quality.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Academic Track

Key session: “Keys to a Successful Academic Hospitalist Program” presented by Robert M. Wachter, MD, University of California, San Francisco; Brian P. Lucas, MD, MS, Cook County Hospital, Chicago; and Adrienne L. Bennett, MD, PhD, Ohio State University Medical Center, Columbus.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Quality Track

Key session: “Improving Quality and Safety during Transitions of Care” presented by Eric Coleman, MD, MPH, University of Colorado, Denver; Jeffrey Greenwald, MD, Boston University Medical Campus; Lakshmi Halasyamani, MD, St. Joseph Mercy Medical Center, Ann Arbor, Mich.; and Mark V. Williams, MD, Northwestern University’s Feinberg School of Medicine in Chicago.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Pediatric Track

Key session: “Surveys Say ... Current Reports on Pediatric Hospitalist Workload and Compensation” presented by Jack Percelay, MD, MPH, FAAP, ELMO Pediatrics, Livingston, N.J., and David Zipes, MD, FAAP, St. Vincent Children’s Hospital, Indianapolis, Ind.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Key session: “Clinical Pathways on a Budget” presented by Steve Narang, MD, Our Lady of the Lake Regional Medical Center, Baton Rouge, La.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.

Couldn’t make it to a session you wanted to attend? Missed the meeting entirely?

This at-a-glance wrap-up provides some highlights from several key sessions:

Clinical Tracks

Key session: “The How, When and Why of Comanagement” presented by Eric M. Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Key session: “Nosocomial Infections and Resistant Organisms” presented by James Pile, MD, FACP, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Operational Track

Key session: “Designing Compensation and Bonus Plans to Drive Desired Behaviors” presented by Rachel M. George, MD, MBA, Cogent Healthcare, Department of Pediatrics at SUNY Downstate Medical Center, Brooklyn, N.Y.; Winthrop Whitcomb, MD, Mercy Medical Center in Springfield, Mass.; and John Bulger DO, FACOI, FACP, Geisinger Health System in Pennsylvania.

Take-away points: Dr. Whitcomb discussed compensation for community-based hospital medicine programs that reward both an individual’s productivity—based on RVUs, charges or cash—and quality measures met, which will directly improve quality.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Academic Track

Key session: “Keys to a Successful Academic Hospitalist Program” presented by Robert M. Wachter, MD, University of California, San Francisco; Brian P. Lucas, MD, MS, Cook County Hospital, Chicago; and Adrienne L. Bennett, MD, PhD, Ohio State University Medical Center, Columbus.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Quality Track

Key session: “Improving Quality and Safety during Transitions of Care” presented by Eric Coleman, MD, MPH, University of Colorado, Denver; Jeffrey Greenwald, MD, Boston University Medical Campus; Lakshmi Halasyamani, MD, St. Joseph Mercy Medical Center, Ann Arbor, Mich.; and Mark V. Williams, MD, Northwestern University’s Feinberg School of Medicine in Chicago.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Pediatric Track

Key session: “Surveys Say ... Current Reports on Pediatric Hospitalist Workload and Compensation” presented by Jack Percelay, MD, MPH, FAAP, ELMO Pediatrics, Livingston, N.J., and David Zipes, MD, FAAP, St. Vincent Children’s Hospital, Indianapolis, Ind.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Key session: “Clinical Pathways on a Budget” presented by Steve Narang, MD, Our Lady of the Lake Regional Medical Center, Baton Rouge, La.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.

A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.

“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”

The Rapid Fire track proved popular with attendees; each topic drew a packed house.

“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”

Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:

“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.

“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.

“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.

“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:

• Prolonged chest pain and normal troponin;
• Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
• Normal troponin and atypical symptoms in the same patient type.

“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:

• 1 mg of protamine for every 100 units of heparin;
• No greater than 50 mg of protamine at one time; and
• Infusion should not exceed 5 mg/min.

“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.

“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”

“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:

• Brain and neurovascular imaging;
• Blood glucose and serum electrolytes;
• Complete blood count with platelets;
• Prothrombin time/partial thromboplastin/international normalized ratio;
• A 12-lead EKG and Holter monitoring;
• Transthoracic echocardiogram/ transesophageal echcardiogram; and
• Supplemental oxygen fever reduction and lipids.

“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.

“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.

A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.

“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”

The Rapid Fire track proved popular with attendees; each topic drew a packed house.

“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”

Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:

“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.

“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.

“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.

“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:

• Prolonged chest pain and normal troponin;
• Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
• Normal troponin and atypical symptoms in the same patient type.

“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:

• 1 mg of protamine for every 100 units of heparin;
• No greater than 50 mg of protamine at one time; and
• Infusion should not exceed 5 mg/min.

“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.

“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”

“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:

• Brain and neurovascular imaging;
• Blood glucose and serum electrolytes;
• Complete blood count with platelets;
• Prothrombin time/partial thromboplastin/international normalized ratio;
• A 12-lead EKG and Holter monitoring;
• Transthoracic echocardiogram/ transesophageal echcardiogram; and
• Supplemental oxygen fever reduction and lipids.

“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.

“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.

A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.

“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”

The Rapid Fire track proved popular with attendees; each topic drew a packed house.

“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”

Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:

“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.

“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.

“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.

“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:

• Prolonged chest pain and normal troponin;
• Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
• Normal troponin and atypical symptoms in the same patient type.

“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:

• 1 mg of protamine for every 100 units of heparin;
• No greater than 50 mg of protamine at one time; and
• Infusion should not exceed 5 mg/min.

“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.

“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”

“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:

• Brain and neurovascular imaging;
• Blood glucose and serum electrolytes;
• Complete blood count with platelets;
• Prothrombin time/partial thromboplastin/international normalized ratio;
• A 12-lead EKG and Holter monitoring;
• Transthoracic echocardiogram/ transesophageal echcardiogram; and
• Supplemental oxygen fever reduction and lipids.

“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.

“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.

Attendees at Hospital Medicine 2008 were the first to hear the results of the latest SHM survey of hospitalists, learning that hospitalist pay is up, roughly one-third of hospitalist leaders don’t know their groups’ expenses or fee revenues, and that financial support has grown substantially.

The society’s biannual survey of U.S. hospital medicine groups went to 1,700 of an estimated 2,200 groups in 2007. SHM Senior Vice President Joseph Miller and Burke Kealey, MD, chair of SHM’s Benchmarks Committee (which designed the survey) presented the findings from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”

“Our purpose is to provide a snapshot of hospital medicine at a moment in time for hospitalists and hospital medicine groups,” Miller said. “I think this is the best SHM survey ever conducted.”

Survey Basics

The survey drew a 24% response rate, gleaning information from 440 hospital medicine groups representing 3,242 individual hospitalists, as well as summary data from a separate survey sent to the nation’s largest hospital medicine groups. “We think it adds to the richness of the data,” explained Miller.

All data were collected between September and December 2007 and reflects information for the previous 12 months. Miller was careful to note that RVU values changed midway through that period.

Hospital medicine still is a young specialty, but, Miller said, “I think we’re seeing a growing experience base.” The median age of hospitalists is 37, with 3.7 years of mean experience. For leaders, the median age is 41, with 6.7 years of experience.

The State of HMGs

Today’s hospital medicine groups are growing, and so is the financial support they receive from hospitals.

“There has been significant growth in the number of [full-time employees] in hospital medicine groups,” Miller said. Since the previous survey two years ago, there is a 31% mean growth in groups. “We’re seeing fewer new groups, with more growth coming from the established groups” More groups are using nurse practitioners and/or physician assistants, up from 29% to 38%.

As for the leadership of the hospital medicine groups, the survey revealed some serious knowledge gaps. “Thirty-five to 37% of leaders did not know the finances of their groups,” Miller pointed out. This percentage—up somewhat from two years ago—could not answer survey questions on their group’s expenses or fee revenue.

The numbers of those who know where their money comes from show that hospitals (or partner institutions) are supplying more financial support now. A whopping 91% of responding programs receive money, with the total mean amount exceeding $97,000 per full-time physician. “This has increased substantially since the last survey,” Miller said.

Productivity and Pay

To ensure clarity of data, the survey breaks down compensation and productivity information for hospitalists into four separate groups: those who treat adult patients; those who treat pediatric patients; those who treat both; and nurse practitioners and physician assistants. In the session, Dr. Kealey covered only the first group.

He pointed out the strong correlation between the number of hours worked and higher productivity, and between higher productivity and higher compensation.

“Encounters have remained relatively flat,” he said. (They are down just 4% from the previous survey.) “But total compensation has increased by 13%.” In other words, hospitalists are working about the same amount they were two years ago, but are making more money—on average, $193,000.

Of the survey respondents, 25.3% are paid by straight salary; 6.1% are paid based on productivity, and the remainder earn a mix of salary and bonus.

Productivity figures show hospitalist experience pays off: Experienced hospitalists have more encounters in the same number of hours than their less-experienced counterparts. They also have higher compensation.

Another disturbing trend among hospitalist leaders is that they put in about as many clinical hours as nonleaders. “This indicates that they may not have enough time to lead,” Dr. Kealey said.

The survey included information on 106 respondents who are nocturnists. These night workers have significantly fewer encounters, and work slightly fewer hours for slightly less money. Dr. Kealey noted that “when you cover nights, your productivity drops. This is good to know if you’re thinking about adding night coverage in your practice.”

The complete survey results should be available sometime in May, and information will be posted on the SHM Web site at www.hospitalmedicine.org.

Attendees at Hospital Medicine 2008 were the first to hear the results of the latest SHM survey of hospitalists, learning that hospitalist pay is up, roughly one-third of hospitalist leaders don’t know their groups’ expenses or fee revenues, and that financial support has grown substantially.

The society’s biannual survey of U.S. hospital medicine groups went to 1,700 of an estimated 2,200 groups in 2007. SHM Senior Vice President Joseph Miller and Burke Kealey, MD, chair of SHM’s Benchmarks Committee (which designed the survey) presented the findings from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”

“Our purpose is to provide a snapshot of hospital medicine at a moment in time for hospitalists and hospital medicine groups,” Miller said. “I think this is the best SHM survey ever conducted.”

Survey Basics

The survey drew a 24% response rate, gleaning information from 440 hospital medicine groups representing 3,242 individual hospitalists, as well as summary data from a separate survey sent to the nation’s largest hospital medicine groups. “We think it adds to the richness of the data,” explained Miller.

All data were collected between September and December 2007 and reflects information for the previous 12 months. Miller was careful to note that RVU values changed midway through that period.

Hospital medicine still is a young specialty, but, Miller said, “I think we’re seeing a growing experience base.” The median age of hospitalists is 37, with 3.7 years of mean experience. For leaders, the median age is 41, with 6.7 years of experience.

The State of HMGs

Today’s hospital medicine groups are growing, and so is the financial support they receive from hospitals.

“There has been significant growth in the number of [full-time employees] in hospital medicine groups,” Miller said. Since the previous survey two years ago, there is a 31% mean growth in groups. “We’re seeing fewer new groups, with more growth coming from the established groups” More groups are using nurse practitioners and/or physician assistants, up from 29% to 38%.

As for the leadership of the hospital medicine groups, the survey revealed some serious knowledge gaps. “Thirty-five to 37% of leaders did not know the finances of their groups,” Miller pointed out. This percentage—up somewhat from two years ago—could not answer survey questions on their group’s expenses or fee revenue.

The numbers of those who know where their money comes from show that hospitals (or partner institutions) are supplying more financial support now. A whopping 91% of responding programs receive money, with the total mean amount exceeding $97,000 per full-time physician. “This has increased substantially since the last survey,” Miller said.

Productivity and Pay

To ensure clarity of data, the survey breaks down compensation and productivity information for hospitalists into four separate groups: those who treat adult patients; those who treat pediatric patients; those who treat both; and nurse practitioners and physician assistants. In the session, Dr. Kealey covered only the first group.

He pointed out the strong correlation between the number of hours worked and higher productivity, and between higher productivity and higher compensation.

“Encounters have remained relatively flat,” he said. (They are down just 4% from the previous survey.) “But total compensation has increased by 13%.” In other words, hospitalists are working about the same amount they were two years ago, but are making more money—on average, $193,000.

Of the survey respondents, 25.3% are paid by straight salary; 6.1% are paid based on productivity, and the remainder earn a mix of salary and bonus.

Productivity figures show hospitalist experience pays off: Experienced hospitalists have more encounters in the same number of hours than their less-experienced counterparts. They also have higher compensation.

Another disturbing trend among hospitalist leaders is that they put in about as many clinical hours as nonleaders. “This indicates that they may not have enough time to lead,” Dr. Kealey said.

The survey included information on 106 respondents who are nocturnists. These night workers have significantly fewer encounters, and work slightly fewer hours for slightly less money. Dr. Kealey noted that “when you cover nights, your productivity drops. This is good to know if you’re thinking about adding night coverage in your practice.”

The complete survey results should be available sometime in May, and information will be posted on the SHM Web site at www.hospitalmedicine.org.

Attendees at Hospital Medicine 2008 were the first to hear the results of the latest SHM survey of hospitalists, learning that hospitalist pay is up, roughly one-third of hospitalist leaders don’t know their groups’ expenses or fee revenues, and that financial support has grown substantially.

The society’s biannual survey of U.S. hospital medicine groups went to 1,700 of an estimated 2,200 groups in 2007. SHM Senior Vice President Joseph Miller and Burke Kealey, MD, chair of SHM’s Benchmarks Committee (which designed the survey) presented the findings from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”

“Our purpose is to provide a snapshot of hospital medicine at a moment in time for hospitalists and hospital medicine groups,” Miller said. “I think this is the best SHM survey ever conducted.”

Survey Basics

The survey drew a 24% response rate, gleaning information from 440 hospital medicine groups representing 3,242 individual hospitalists, as well as summary data from a separate survey sent to the nation’s largest hospital medicine groups. “We think it adds to the richness of the data,” explained Miller.

All data were collected between September and December 2007 and reflects information for the previous 12 months. Miller was careful to note that RVU values changed midway through that period.

Hospital medicine still is a young specialty, but, Miller said, “I think we’re seeing a growing experience base.” The median age of hospitalists is 37, with 3.7 years of mean experience. For leaders, the median age is 41, with 6.7 years of experience.

The State of HMGs

Today’s hospital medicine groups are growing, and so is the financial support they receive from hospitals.

“There has been significant growth in the number of [full-time employees] in hospital medicine groups,” Miller said. Since the previous survey two years ago, there is a 31% mean growth in groups. “We’re seeing fewer new groups, with more growth coming from the established groups” More groups are using nurse practitioners and/or physician assistants, up from 29% to 38%.

As for the leadership of the hospital medicine groups, the survey revealed some serious knowledge gaps. “Thirty-five to 37% of leaders did not know the finances of their groups,” Miller pointed out. This percentage—up somewhat from two years ago—could not answer survey questions on their group’s expenses or fee revenue.

The numbers of those who know where their money comes from show that hospitals (or partner institutions) are supplying more financial support now. A whopping 91% of responding programs receive money, with the total mean amount exceeding $97,000 per full-time physician. “This has increased substantially since the last survey,” Miller said.

Productivity and Pay

To ensure clarity of data, the survey breaks down compensation and productivity information for hospitalists into four separate groups: those who treat adult patients; those who treat pediatric patients; those who treat both; and nurse practitioners and physician assistants. In the session, Dr. Kealey covered only the first group.

He pointed out the strong correlation between the number of hours worked and higher productivity, and between higher productivity and higher compensation.

“Encounters have remained relatively flat,” he said. (They are down just 4% from the previous survey.) “But total compensation has increased by 13%.” In other words, hospitalists are working about the same amount they were two years ago, but are making more money—on average, $193,000.

Of the survey respondents, 25.3% are paid by straight salary; 6.1% are paid based on productivity, and the remainder earn a mix of salary and bonus.

Productivity figures show hospitalist experience pays off: Experienced hospitalists have more encounters in the same number of hours than their less-experienced counterparts. They also have higher compensation.

Another disturbing trend among hospitalist leaders is that they put in about as many clinical hours as nonleaders. “This indicates that they may not have enough time to lead,” Dr. Kealey said.

The survey included information on 106 respondents who are nocturnists. These night workers have significantly fewer encounters, and work slightly fewer hours for slightly less money. Dr. Kealey noted that “when you cover nights, your productivity drops. This is good to know if you’re thinking about adding night coverage in your practice.”

The complete survey results should be available sometime in May, and information will be posted on the SHM Web site at www.hospitalmedicine.org.

Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

Dr. Li

Hospitalists across the nation stand ready for a possible shortage of Baxter Healthcare Corporation-produced heparin, a blood thinner linked to 785 reported serious injuries and 19 deaths.

The initial January recall of multidose vials of the anticoagulant—used for surgery, dialysis and for the bedridden—broadened in February after magnetic resonance imaging tests uncovered that as much as 20% of the product’s active ingredient was a heparin mimic blended in with the actual product. The most serious injuries and death occurred in patients who received high doses of heparin during short periods of time.

The contaminant, an altered form of chondroitin sulfate, was identified in March.

Heparin is made from pig intestines. The raw product bought by the Waunaukee, Wis.-based Scientific Protein Laboratories was produced in small, unregulated family workshops in China and processed in plants in Wisconsin and China, according to heparin traders and producers in China. Baxter sells the finished product.

Pharmacist Gerard Barber of the University of Colorado Hospital sent an e-mail to staff there warning of the “erratic supply chain” caused by the heparin recall involving Baxter-produced heparin products.

“Ultimately there may be a true short supply of heparin, particularly when used subcutaneously for prophylaxis of DVTs—but we have managed to maintain an adequate supply of heparin product thus far,” he wrote in a March 7 e-mail.

Barber says the Department of Pharmacy has been aware of the situation since early February and took the added precaution of sequestering the product.

“Currently, we have managed to secure enough heparin product to avoid therapeutic interchanges to other heparin volumes (e.g., 5,000 units per 0.5 mL to 5,000 units per 1 mL) thus far,” he wrote.

Barber was still trying to procure “the same concentrations of heparin we’ve long used” in April.

“For as much heparin as all the [doctors] use, with the widened recall we’re particularly keeping an eye on other sizes (1,000 units/mL, 30 mL) for areas very, very dependent on the drug such as dialysis and perfusion for cardiothoracic surgery,” Barber says. “In areas like these it would be very difficult if at all possible to use alternative agents as we could if needed for DVTs and switching to low-molecular weight products.”

Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, says it will be incumbent upon other manufacturers to “ramp up” production of the drug.

“Certainly, if hospitalists were unable to use unfractionated heparin, providers can reach for low molecular weight heparin [LMWH] products,” he says.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for the Sentara Medical Group in Norfolk, Va., agrees with Dr. Li that use of LMWH could be a viable alternative.

“The impact in our system has been directed by the clinical pharmacists,” he says when asked how his group is handling the recalls. “We have received no notification regarding heparin that we presently use.”

Baxter International Inc., announced Feb. 28 it would voluntarily recall all remaining lots and doses of its heparin sodium injection multidose and single-dose vials, as well as its HEP-LOCK heparin flush products, according to a press release posted on the U.S. Food and Drug Administration’s Web site.

On Jan. 17, the company initially recalled nine lots of heparin sodium injection multidose vials as a precautionary measure due to a “higher than usual number of reports of adverse patient reactions,” the release noted.

Nearly all adverse reactions were seen in patients receiving high doses of heparin during short periods of time. Reactions patients reported included difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure, which in some cases led to life-threatening shock. Such reactions were not seen in patients receiving lower doses of the drug or those who received higher doses over longer periods. TH

Molly R. Okeon is a journalist based in California.

Dr. Li

Hospitalists across the nation stand ready for a possible shortage of Baxter Healthcare Corporation-produced heparin, a blood thinner linked to 785 reported serious injuries and 19 deaths.

The initial January recall of multidose vials of the anticoagulant—used for surgery, dialysis and for the bedridden—broadened in February after magnetic resonance imaging tests uncovered that as much as 20% of the product’s active ingredient was a heparin mimic blended in with the actual product. The most serious injuries and death occurred in patients who received high doses of heparin during short periods of time.

The contaminant, an altered form of chondroitin sulfate, was identified in March.

Heparin is made from pig intestines. The raw product bought by the Waunaukee, Wis.-based Scientific Protein Laboratories was produced in small, unregulated family workshops in China and processed in plants in Wisconsin and China, according to heparin traders and producers in China. Baxter sells the finished product.

Pharmacist Gerard Barber of the University of Colorado Hospital sent an e-mail to staff there warning of the “erratic supply chain” caused by the heparin recall involving Baxter-produced heparin products.

“Ultimately there may be a true short supply of heparin, particularly when used subcutaneously for prophylaxis of DVTs—but we have managed to maintain an adequate supply of heparin product thus far,” he wrote in a March 7 e-mail.

Barber says the Department of Pharmacy has been aware of the situation since early February and took the added precaution of sequestering the product.

“Currently, we have managed to secure enough heparin product to avoid therapeutic interchanges to other heparin volumes (e.g., 5,000 units per 0.5 mL to 5,000 units per 1 mL) thus far,” he wrote.

Barber was still trying to procure “the same concentrations of heparin we’ve long used” in April.

“For as much heparin as all the [doctors] use, with the widened recall we’re particularly keeping an eye on other sizes (1,000 units/mL, 30 mL) for areas very, very dependent on the drug such as dialysis and perfusion for cardiothoracic surgery,” Barber says. “In areas like these it would be very difficult if at all possible to use alternative agents as we could if needed for DVTs and switching to low-molecular weight products.”

Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, says it will be incumbent upon other manufacturers to “ramp up” production of the drug.

“Certainly, if hospitalists were unable to use unfractionated heparin, providers can reach for low molecular weight heparin [LMWH] products,” he says.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for the Sentara Medical Group in Norfolk, Va., agrees with Dr. Li that use of LMWH could be a viable alternative.

“The impact in our system has been directed by the clinical pharmacists,” he says when asked how his group is handling the recalls. “We have received no notification regarding heparin that we presently use.”

Baxter International Inc., announced Feb. 28 it would voluntarily recall all remaining lots and doses of its heparin sodium injection multidose and single-dose vials, as well as its HEP-LOCK heparin flush products, according to a press release posted on the U.S. Food and Drug Administration’s Web site.

On Jan. 17, the company initially recalled nine lots of heparin sodium injection multidose vials as a precautionary measure due to a “higher than usual number of reports of adverse patient reactions,” the release noted.

Nearly all adverse reactions were seen in patients receiving high doses of heparin during short periods of time. Reactions patients reported included difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure, which in some cases led to life-threatening shock. Such reactions were not seen in patients receiving lower doses of the drug or those who received higher doses over longer periods. TH

Molly R. Okeon is a journalist based in California.

Dr. Li

Hospitalists across the nation stand ready for a possible shortage of Baxter Healthcare Corporation-produced heparin, a blood thinner linked to 785 reported serious injuries and 19 deaths.

The initial January recall of multidose vials of the anticoagulant—used for surgery, dialysis and for the bedridden—broadened in February after magnetic resonance imaging tests uncovered that as much as 20% of the product’s active ingredient was a heparin mimic blended in with the actual product. The most serious injuries and death occurred in patients who received high doses of heparin during short periods of time.

The contaminant, an altered form of chondroitin sulfate, was identified in March.

Heparin is made from pig intestines. The raw product bought by the Waunaukee, Wis.-based Scientific Protein Laboratories was produced in small, unregulated family workshops in China and processed in plants in Wisconsin and China, according to heparin traders and producers in China. Baxter sells the finished product.

Pharmacist Gerard Barber of the University of Colorado Hospital sent an e-mail to staff there warning of the “erratic supply chain” caused by the heparin recall involving Baxter-produced heparin products.

“Ultimately there may be a true short supply of heparin, particularly when used subcutaneously for prophylaxis of DVTs—but we have managed to maintain an adequate supply of heparin product thus far,” he wrote in a March 7 e-mail.

Barber says the Department of Pharmacy has been aware of the situation since early February and took the added precaution of sequestering the product.

“Currently, we have managed to secure enough heparin product to avoid therapeutic interchanges to other heparin volumes (e.g., 5,000 units per 0.5 mL to 5,000 units per 1 mL) thus far,” he wrote.

Barber was still trying to procure “the same concentrations of heparin we’ve long used” in April.

“For as much heparin as all the [doctors] use, with the widened recall we’re particularly keeping an eye on other sizes (1,000 units/mL, 30 mL) for areas very, very dependent on the drug such as dialysis and perfusion for cardiothoracic surgery,” Barber says. “In areas like these it would be very difficult if at all possible to use alternative agents as we could if needed for DVTs and switching to low-molecular weight products.”

Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, says it will be incumbent upon other manufacturers to “ramp up” production of the drug.

“Certainly, if hospitalists were unable to use unfractionated heparin, providers can reach for low molecular weight heparin [LMWH] products,” he says.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for the Sentara Medical Group in Norfolk, Va., agrees with Dr. Li that use of LMWH could be a viable alternative.

“The impact in our system has been directed by the clinical pharmacists,” he says when asked how his group is handling the recalls. “We have received no notification regarding heparin that we presently use.”

Baxter International Inc., announced Feb. 28 it would voluntarily recall all remaining lots and doses of its heparin sodium injection multidose and single-dose vials, as well as its HEP-LOCK heparin flush products, according to a press release posted on the U.S. Food and Drug Administration’s Web site.

On Jan. 17, the company initially recalled nine lots of heparin sodium injection multidose vials as a precautionary measure due to a “higher than usual number of reports of adverse patient reactions,” the release noted.

Nearly all adverse reactions were seen in patients receiving high doses of heparin during short periods of time. Reactions patients reported included difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure, which in some cases led to life-threatening shock. Such reactions were not seen in patients receiving lower doses of the drug or those who received higher doses over longer periods. TH

Molly R. Okeon is a journalist based in California.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

SAN DIEGO—Eleven years ago, about 100 physicians gathered in San Diego for a meeting of the National Association of Inpatient Physicians (NAIP). The term “hospitalist” had been coined only two years earlier for a fledgling specialty.

Fast forward to April 3, when NAIP—now SHM—returned to this city with 1,600 attendees for the largest gathering of hospitalists to date. This meeting, Hospital Medicine 2008, showcased a multitude of the society’s newest and boldest efforts.

Hot-off-the-presses data from the Society of Hospital Medicine 2007-2008 Survey were unveiled, showing hospitalists are getting paid more to do roughly the same amount of work they’d been doing. SHM also announced an upcoming Fellowship in Hospital Medicine credential, to be the first designation of commitment to the field. While handing over the reins to his successor Patrick J. Cawley, MD, outgoing SHM President Rusty Holman, MD, announced the development of a Hospital Care Collaborative that will foster cooperation among hospitalists, critical care nurses, pharmacists, and other hospital medicine stakeholders.

Attendees flocked to SHM’s new Rapid Fire clinical track for evidence-based answers to common question, delivered at a breakneck pace. For the first time, an award for Team Approaches in Quality Improvement was among those bestowed at the President’s Lunch. The winning project, “Optimizing Prevention of Hospital-Acquired Venous Thromboembolism,” was the creation of a team from the University of California, San Diego led by Gregory Maynard, MD, professor of clinical medicine and chief of the division of hospital medicine.

The future of our healthcare system and the role hospital medicine will play were uppermost on the minds of keynote speakers Don Berwick, MD, of the Institute for Healthcare Improvement (IHI), healthcare futurist Ian Morrison, PhD, and Robert Wachter, MD, each of whom peered into their crystal balls to give hospitalists glimpses of the challenges and opportunities they might expect. Each urged hospitalists to assert their place in the forefront of reimagining the U.S. care system and claim a leading role in whatever system that might be.

A First Time for Everything

The meeting produced many firsts in the educational content provided, thanks to SHM’s Annual Meeting Committee, led by course director Sylvia McKean, MD.

“We did change some things,” Dr. McKean said. “We had a call for proposals for speakers and sessions, and picked up a session in the operational track, in the clinical track and in Rapid Fire. We got a tremendous response to this, and this was the first time we’d ever had an open call like that.”

Several of the all-day pre-courses were revamped or entirely new. Also new was the Rapid Fire track, which provided answers to dilemmas in critical care, perioperative cardiac, care and more—all in rapid bursts of information.

There also were more special-interest forums, offering an opportunity for all subsets under the tent of hospital medicine—from geriatric hospitalists to women hospitalists to rural hospitalists—to network and compare notes.

Another opportunity to network for those with strong lungs was the inaugural SHM Fun Run early April 5. Participants ran a 5K course along San Diego’s waterfront.

SHM Announces Firsts

At the President’s Lunch on April 5, SHM leaders unveiled plans for several initiatives that will continue to foster and improve hospital medicine.

Dr. Holman outlined recent SHM successes and introduced upcoming initiatives. Successes include the society’s policy and advocacy agenda. SHM members generated 1,700 letters to Congress in 2007 through the online Legislative Action Center and added their voices to a successful lobby to postpone a 10.1% physician pay cut by Medicare last year. He also discussed his appearance at a Senate roundtable March 6 on Capitol Hill to discuss Medicare’s value-based purchasing of hospital care.

SHM is also front and center regarding transitions of care, and has been charged with developing transition quality measures for consideration in reporting initiatives.

As for future initiatives, Dr. Holman told attendees about SHM’s plan for a Hospital Care Collaborative. The society will partner with national organizations in allied health, including the American Association of Critical-Care Nurses and the American Society of Health-System Pharmacists. All will work together on common policies and implementation strategies.

The society also will provide more resources for hospitalist leaders. “SHM wants to be positioned to support leadership training,” Dr. Holman noted. “We have a multiyear plan” that includes creating core competencies for hospital medicine leadership, a possible leadership certification, a mentoring program, and leadership coaching.

SHM CEO Larry Wellikson, MD, summed up the tremendous growth of hospital medicine: “We’re large and in charge, and we’re only going to get bigger.” He elaborated on progress made on SHM initiatives that will enhance this growth, including:

• Continued monitoring of the first official certification for hospital medicine, the American Board of Internal Medicine (ABIM)-approved Focused Recognition for Hospital Medicine;
• Creation of the first designation of commitment to the practice of hospital medicine: the SHM Fellowship in Hospital Medicine (FHM) credential. A Senior Fellowship in Hospital Medicine and a Master in Hospital Medicine will also be available. Information and applications will be available this fall, and all SHM members can apply;
• Continued use of new media to educate and inform members; and
• One- or two-day regional educational forums across the U.S.

Dr. Cawley, chief medical officer of Medical University of South Carolina Medical Center in Charleston, closed the President’s Lunch by echoing the speakers’ message for hospitalists. “Change is in the air,” he asserted, recalling the last time healthcare was poised for big change, when President Clinton was prepared to overhaul the system in 1993. “The difference between 1993 and 2008 is you—it’s hospitalists,” Dr. Cawley urged. “You are the guiding team” for change.

Also during Saturday’s luncheon, outgoing SHM board members Bill Atchley, MD, and Mary Jo Gorman, MD, were honored for their six years of service.

Focus on the Future

Hospital Medicine 2008 was firmly focused on the future: the future of American healthcare, the future of hospital medicine, and what hospitalists will and should do to further their specialty. These themes surfaced again and again in the plenaries, in breakout sessions, and in casual hallway conversations.

Drs. Berwick and Morrison stirred up attendees with their morning addresses and had them debating the state of healthcare. Dr. Wachter, professor and associate chairman, department of medicine, and chief of the medical service, University of California, San Francisco, offered his unique perspective by taking Drs. Berwick and Morrison’s 35,000-foot-view and bringing it down to the day-to-day work of hospitalists. The creator of the popular healthcare blog “Wachter’s World” (www.wachtersworld. org) suggested “megatrends” hospitalists might expect to see, including:

• The growth of local pay-for-performance (bonuses based on performance) and state reporting systems, and a shift toward outcome measurement as opposed to process measures;
• The power of public reporting, driven by the “simple embarrassment of highlighting underperformers”;
• Zero tolerance for “disruptive” physicians;
• Ever-increasing hospitalist-surgical comanagement; and
• IT-induced “dislocation” of medicine as computerization decreases the need for physical presence, as well as the emergence of IT haves and have-nots.

Jane Jerrard, a Chicago-based medical journalist, writes the “Public Policy” and “Career Development” departments for The Hospitalist and has covered the SHM Annual Meeting the past three years.

SAN DIEGO—Eleven years ago, about 100 physicians gathered in San Diego for a meeting of the National Association of Inpatient Physicians (NAIP). The term “hospitalist” had been coined only two years earlier for a fledgling specialty.

Fast forward to April 3, when NAIP—now SHM—returned to this city with 1,600 attendees for the largest gathering of hospitalists to date. This meeting, Hospital Medicine 2008, showcased a multitude of the society’s newest and boldest efforts.

Hot-off-the-presses data from the Society of Hospital Medicine 2007-2008 Survey were unveiled, showing hospitalists are getting paid more to do roughly the same amount of work they’d been doing. SHM also announced an upcoming Fellowship in Hospital Medicine credential, to be the first designation of commitment to the field. While handing over the reins to his successor Patrick J. Cawley, MD, outgoing SHM President Rusty Holman, MD, announced the development of a Hospital Care Collaborative that will foster cooperation among hospitalists, critical care nurses, pharmacists, and other hospital medicine stakeholders.

Attendees flocked to SHM’s new Rapid Fire clinical track for evidence-based answers to common question, delivered at a breakneck pace. For the first time, an award for Team Approaches in Quality Improvement was among those bestowed at the President’s Lunch. The winning project, “Optimizing Prevention of Hospital-Acquired Venous Thromboembolism,” was the creation of a team from the University of California, San Diego led by Gregory Maynard, MD, professor of clinical medicine and chief of the division of hospital medicine.

The future of our healthcare system and the role hospital medicine will play were uppermost on the minds of keynote speakers Don Berwick, MD, of the Institute for Healthcare Improvement (IHI), healthcare futurist Ian Morrison, PhD, and Robert Wachter, MD, each of whom peered into their crystal balls to give hospitalists glimpses of the challenges and opportunities they might expect. Each urged hospitalists to assert their place in the forefront of reimagining the U.S. care system and claim a leading role in whatever system that might be.

A First Time for Everything

The meeting produced many firsts in the educational content provided, thanks to SHM’s Annual Meeting Committee, led by course director Sylvia McKean, MD.

“We did change some things,” Dr. McKean said. “We had a call for proposals for speakers and sessions, and picked up a session in the operational track, in the clinical track and in Rapid Fire. We got a tremendous response to this, and this was the first time we’d ever had an open call like that.”

Several of the all-day pre-courses were revamped or entirely new. Also new was the Rapid Fire track, which provided answers to dilemmas in critical care, perioperative cardiac, care and more—all in rapid bursts of information.

There also were more special-interest forums, offering an opportunity for all subsets under the tent of hospital medicine—from geriatric hospitalists to women hospitalists to rural hospitalists—to network and compare notes.

Another opportunity to network for those with strong lungs was the inaugural SHM Fun Run early April 5. Participants ran a 5K course along San Diego’s waterfront.

SHM Announces Firsts

At the President’s Lunch on April 5, SHM leaders unveiled plans for several initiatives that will continue to foster and improve hospital medicine.

Dr. Holman outlined recent SHM successes and introduced upcoming initiatives. Successes include the society’s policy and advocacy agenda. SHM members generated 1,700 letters to Congress in 2007 through the online Legislative Action Center and added their voices to a successful lobby to postpone a 10.1% physician pay cut by Medicare last year. He also discussed his appearance at a Senate roundtable March 6 on Capitol Hill to discuss Medicare’s value-based purchasing of hospital care.

SHM is also front and center regarding transitions of care, and has been charged with developing transition quality measures for consideration in reporting initiatives.

As for future initiatives, Dr. Holman told attendees about SHM’s plan for a Hospital Care Collaborative. The society will partner with national organizations in allied health, including the American Association of Critical-Care Nurses and the American Society of Health-System Pharmacists. All will work together on common policies and implementation strategies.

The society also will provide more resources for hospitalist leaders. “SHM wants to be positioned to support leadership training,” Dr. Holman noted. “We have a multiyear plan” that includes creating core competencies for hospital medicine leadership, a possible leadership certification, a mentoring program, and leadership coaching.

SHM CEO Larry Wellikson, MD, summed up the tremendous growth of hospital medicine: “We’re large and in charge, and we’re only going to get bigger.” He elaborated on progress made on SHM initiatives that will enhance this growth, including:

• Continued monitoring of the first official certification for hospital medicine, the American Board of Internal Medicine (ABIM)-approved Focused Recognition for Hospital Medicine;
• Creation of the first designation of commitment to the practice of hospital medicine: the SHM Fellowship in Hospital Medicine (FHM) credential. A Senior Fellowship in Hospital Medicine and a Master in Hospital Medicine will also be available. Information and applications will be available this fall, and all SHM members can apply;
• Continued use of new media to educate and inform members; and
• One- or two-day regional educational forums across the U.S.

Dr. Cawley, chief medical officer of Medical University of South Carolina Medical Center in Charleston, closed the President’s Lunch by echoing the speakers’ message for hospitalists. “Change is in the air,” he asserted, recalling the last time healthcare was poised for big change, when President Clinton was prepared to overhaul the system in 1993. “The difference between 1993 and 2008 is you—it’s hospitalists,” Dr. Cawley urged. “You are the guiding team” for change.

Also during Saturday’s luncheon, outgoing SHM board members Bill Atchley, MD, and Mary Jo Gorman, MD, were honored for their six years of service.

Focus on the Future

Hospital Medicine 2008 was firmly focused on the future: the future of American healthcare, the future of hospital medicine, and what hospitalists will and should do to further their specialty. These themes surfaced again and again in the plenaries, in breakout sessions, and in casual hallway conversations.

Drs. Berwick and Morrison stirred up attendees with their morning addresses and had them debating the state of healthcare. Dr. Wachter, professor and associate chairman, department of medicine, and chief of the medical service, University of California, San Francisco, offered his unique perspective by taking Drs. Berwick and Morrison’s 35,000-foot-view and bringing it down to the day-to-day work of hospitalists. The creator of the popular healthcare blog “Wachter’s World” (www.wachtersworld. org) suggested “megatrends” hospitalists might expect to see, including:

• The growth of local pay-for-performance (bonuses based on performance) and state reporting systems, and a shift toward outcome measurement as opposed to process measures;
• The power of public reporting, driven by the “simple embarrassment of highlighting underperformers”;
• Zero tolerance for “disruptive” physicians;
• Ever-increasing hospitalist-surgical comanagement; and
• IT-induced “dislocation” of medicine as computerization decreases the need for physical presence, as well as the emergence of IT haves and have-nots.

Jane Jerrard, a Chicago-based medical journalist, writes the “Public Policy” and “Career Development” departments for The Hospitalist and has covered the SHM Annual Meeting the past three years.

SAN DIEGO—Eleven years ago, about 100 physicians gathered in San Diego for a meeting of the National Association of Inpatient Physicians (NAIP). The term “hospitalist” had been coined only two years earlier for a fledgling specialty.

Fast forward to April 3, when NAIP—now SHM—returned to this city with 1,600 attendees for the largest gathering of hospitalists to date. This meeting, Hospital Medicine 2008, showcased a multitude of the society’s newest and boldest efforts.

Hot-off-the-presses data from the Society of Hospital Medicine 2007-2008 Survey were unveiled, showing hospitalists are getting paid more to do roughly the same amount of work they’d been doing. SHM also announced an upcoming Fellowship in Hospital Medicine credential, to be the first designation of commitment to the field. While handing over the reins to his successor Patrick J. Cawley, MD, outgoing SHM President Rusty Holman, MD, announced the development of a Hospital Care Collaborative that will foster cooperation among hospitalists, critical care nurses, pharmacists, and other hospital medicine stakeholders.

Attendees flocked to SHM’s new Rapid Fire clinical track for evidence-based answers to common question, delivered at a breakneck pace. For the first time, an award for Team Approaches in Quality Improvement was among those bestowed at the President’s Lunch. The winning project, “Optimizing Prevention of Hospital-Acquired Venous Thromboembolism,” was the creation of a team from the University of California, San Diego led by Gregory Maynard, MD, professor of clinical medicine and chief of the division of hospital medicine.

The future of our healthcare system and the role hospital medicine will play were uppermost on the minds of keynote speakers Don Berwick, MD, of the Institute for Healthcare Improvement (IHI), healthcare futurist Ian Morrison, PhD, and Robert Wachter, MD, each of whom peered into their crystal balls to give hospitalists glimpses of the challenges and opportunities they might expect. Each urged hospitalists to assert their place in the forefront of reimagining the U.S. care system and claim a leading role in whatever system that might be.

A First Time for Everything

The meeting produced many firsts in the educational content provided, thanks to SHM’s Annual Meeting Committee, led by course director Sylvia McKean, MD.

“We did change some things,” Dr. McKean said. “We had a call for proposals for speakers and sessions, and picked up a session in the operational track, in the clinical track and in Rapid Fire. We got a tremendous response to this, and this was the first time we’d ever had an open call like that.”

Several of the all-day pre-courses were revamped or entirely new. Also new was the Rapid Fire track, which provided answers to dilemmas in critical care, perioperative cardiac, care and more—all in rapid bursts of information.

There also were more special-interest forums, offering an opportunity for all subsets under the tent of hospital medicine—from geriatric hospitalists to women hospitalists to rural hospitalists—to network and compare notes.

Another opportunity to network for those with strong lungs was the inaugural SHM Fun Run early April 5. Participants ran a 5K course along San Diego’s waterfront.

SHM Announces Firsts

At the President’s Lunch on April 5, SHM leaders unveiled plans for several initiatives that will continue to foster and improve hospital medicine.

Dr. Holman outlined recent SHM successes and introduced upcoming initiatives. Successes include the society’s policy and advocacy agenda. SHM members generated 1,700 letters to Congress in 2007 through the online Legislative Action Center and added their voices to a successful lobby to postpone a 10.1% physician pay cut by Medicare last year. He also discussed his appearance at a Senate roundtable March 6 on Capitol Hill to discuss Medicare’s value-based purchasing of hospital care.

SHM is also front and center regarding transitions of care, and has been charged with developing transition quality measures for consideration in reporting initiatives.

As for future initiatives, Dr. Holman told attendees about SHM’s plan for a Hospital Care Collaborative. The society will partner with national organizations in allied health, including the American Association of Critical-Care Nurses and the American Society of Health-System Pharmacists. All will work together on common policies and implementation strategies.

The society also will provide more resources for hospitalist leaders. “SHM wants to be positioned to support leadership training,” Dr. Holman noted. “We have a multiyear plan” that includes creating core competencies for hospital medicine leadership, a possible leadership certification, a mentoring program, and leadership coaching.

SHM CEO Larry Wellikson, MD, summed up the tremendous growth of hospital medicine: “We’re large and in charge, and we’re only going to get bigger.” He elaborated on progress made on SHM initiatives that will enhance this growth, including:

• Continued monitoring of the first official certification for hospital medicine, the American Board of Internal Medicine (ABIM)-approved Focused Recognition for Hospital Medicine;
• Creation of the first designation of commitment to the practice of hospital medicine: the SHM Fellowship in Hospital Medicine (FHM) credential. A Senior Fellowship in Hospital Medicine and a Master in Hospital Medicine will also be available. Information and applications will be available this fall, and all SHM members can apply;
• Continued use of new media to educate and inform members; and
• One- or two-day regional educational forums across the U.S.

Dr. Cawley, chief medical officer of Medical University of South Carolina Medical Center in Charleston, closed the President’s Lunch by echoing the speakers’ message for hospitalists. “Change is in the air,” he asserted, recalling the last time healthcare was poised for big change, when President Clinton was prepared to overhaul the system in 1993. “The difference between 1993 and 2008 is you—it’s hospitalists,” Dr. Cawley urged. “You are the guiding team” for change.

Also during Saturday’s luncheon, outgoing SHM board members Bill Atchley, MD, and Mary Jo Gorman, MD, were honored for their six years of service.

Focus on the Future

Hospital Medicine 2008 was firmly focused on the future: the future of American healthcare, the future of hospital medicine, and what hospitalists will and should do to further their specialty. These themes surfaced again and again in the plenaries, in breakout sessions, and in casual hallway conversations.

Drs. Berwick and Morrison stirred up attendees with their morning addresses and had them debating the state of healthcare. Dr. Wachter, professor and associate chairman, department of medicine, and chief of the medical service, University of California, San Francisco, offered his unique perspective by taking Drs. Berwick and Morrison’s 35,000-foot-view and bringing it down to the day-to-day work of hospitalists. The creator of the popular healthcare blog “Wachter’s World” (www.wachtersworld. org) suggested “megatrends” hospitalists might expect to see, including:

• The growth of local pay-for-performance (bonuses based on performance) and state reporting systems, and a shift toward outcome measurement as opposed to process measures;
• The power of public reporting, driven by the “simple embarrassment of highlighting underperformers”;
• Zero tolerance for “disruptive” physicians;
• Ever-increasing hospitalist-surgical comanagement; and
• IT-induced “dislocation” of medicine as computerization decreases the need for physical presence, as well as the emergence of IT haves and have-nots.

Jane Jerrard, a Chicago-based medical journalist, writes the “Public Policy” and “Career Development” departments for The Hospitalist and has covered the SHM Annual Meeting the past three years.

More than 2 years have passed since we published the results of the Women’s Health Initiative (WHI), which caused a storm of information—and misinformation—about the effect of long-term dietary intervention on disease outcomes in postmenopausal women. Now that the dust has long settled, what have we learned from this landmark study?

The WHI results led to numerous additional analyses of all aspects of the study.^1–7 What are the implications of all the analyses to clinical practice?

In this article, we summarize key aspects of the clinical trial, including study design, interventions, main results, and future plans. We also discuss potential clinical applications and practical considerations for public health efforts.

WHO WAS ELIGIBLE, WHO WAS NOT

A total of 48,835 postmenopausal women were randomly assigned to either no dietary intervention (n = 29,294) or a dietary intervention (n = 19,541) (see below).⁷ Participants were followed at 40 clinical centers between 1993 and 2005.⁴ Their mean age was 62.3 years; 18.6% were members of minorities.

Women were eligible if they were post-menopausal and had a daily dietary fat intake of at least 32% of total calories, based on assessment via a food-frequency questionnaire. They were excluded from the study if they had any of the following: a history of breast cancer, colorectal cancer, or other cancer except skin cancer during the past 10 years; type 1 diabetes; a medical condition in which the predicted survival was less than 3 years; and a potential barrier to adherence to the study regimen, including alcoholism or a lifestyle that involved often eating meals away from home.

THE WHI DIET: LESS FAT, BUT MORE FRUITS, VEGETABLES, GRAINS

The WHI dietary intervention was designed to prevent breast cancer, based on the evidence available when the study was planned. The targets included a total fat intake of less than 20% of energy (in kilocalories), increasing the intake of fruits and vegetables to at least five servings per day, and increasing the intake of grains to at least six servings per day.

Although reduction in saturated fat intake per se was not part of the WHI protocol, we assumed from previous pilot studies⁸ that the reduction of total fat intake would simultaneously produce a reduction in saturated fat intake to 7% of total calories.

A simpler dietary intervention

Unlike the 2006 American Heart Association guidelines and the US Department of Agriculture’s Dietary Guidelines for Americans 2005, the WHI dietary intervention had no specifications for dietary fiber, specific fatty acids (trans-fatty acids, omega-3 fatty acids, conjugated linoleic acid), complex carbohydrates, whole grains, vegetable protein, or other factors that have emerged as potential risk factors for cardiovascular and other chronic diseases since the study began. The WHI intervention also included no specific recommendation for total calorie intake, nor were patients in the intervention group encouraged to lose weight, as this could have confounded the results of the dietary intervention.

Education and encouragement

Those in the intervention group were each assigned a fat-gram goal, calculated on the basis of height. They were taught how to monitor their intake of total fat, fruits, vegetables, and grains. They attended intensive behavioral modification sessions to encourage them to keep to the dietary program: 18 group sessions in the first year and quarterly maintenance sessions thereafter, touching on a wide variety of nutrition- and behavior-related topics.^7,9 Specially trained and certified nutritionists supervised the dietary intervention and the behavioral modification sessions according to the WHI study protocol.

Control-group participants received a copy of the US Department of Agriculture’s Dietary Guidelines for Americans¹⁰ and other health-related materials. They had no contact with the study nutritionists.

Other arms of the study

The WHI trial design included several arms,^4,11–13 and many participants joined more than one arm: 20,592 postmenopausal women (42.2% of the total enrollment) chose dietary modification only, 8,050 (16.5%) chose diet plus hormone replacement therapy, 25,210 (51.6%) chose diet plus calcium and vitamin D supplementation, and 5,017 (10.3%) enrolled in all three.

Length of follow-up

Participants were followed from enrollment until they died, were lost to follow-up, or requested no further contact, or until the trial’s planned completion date, regardless of adherence to the dietary intervention, according to intention-to-treat analysis. All participants were contacted by clinic staff at 6-month intervals to provide updates on their health outcomes.

Factors assessed

Height, weight, waist circumference, and blood pressure were measured at annual visits using standardized procedures. Fasting blood samples were collected at baseline and at year 1 from all participants and from a subsample of 2,816 women (5.8% of the study population) at years 3 and 6. This subsample was randomly chosen with oversampling of minority women, for whom the odds for selection were six times higher than for white women.

Physical activity was assessed at baseline and at years 1, 3, 6, and 9. Walking and participation in sports and hours of activity per week were calculated for each participant. Physical activity was expressed as metabolic equivalent tasks per week for the analyses.

A food-frequency questionnaire⁶ to assess average dietary intake in the past 3 months was given at baseline and at year 1 for all participants. A third of all participants completed the questionnaire each year in a rotating sample. Completion rates were 100% at baseline and 81% thereafter. Follow-up data were collected from years 5 through 7. Also, 4-day food records were provided by all women before randomization.

HOW OUTCOMES WERE ASSESSED

The primary assessments of clinical outcome^1–3 were mammographic screening, a self-reported medical history documented by a review of medical records, and electrocardiograms digitally obtained every 3 years. Mammograms and electrocardiograms were centrally adjudicated. The diagnosis of acute myocardial infarction was based on an algorithm that included cardiac pain, enzyme levels, and electrocardiographic readings.

OVERALL RESULTS

At 8.1 years, the incidence of breast cancer was 9% lower in the intervention group than in the comparison group (95% confidence interval [CI] = 0.83–1.01; P = .07, P = .09 weighted for length of follow-up).³ Subgroup analysis further showed that women who reported higher intakes of total dietary fat at baseline reduced their risk of breast cancer by 22% (95% CI = 0.64–0.96). Whether extended follow-up will show a significant association has yet to be determined.

Colon cancer rates did not differ between groups, but the number of polyps and adenomas reported was significantly lower in the dietary intervention group.¹ The rate of colon cancer will also be included in the extended follow-up study of the WHI.

Risk factors for coronary heart disease in both groups—including levels of serum total cholesterol and serum low-density lipoprotein cholesterol, body weight, body mass index, diastolic blood pressure, and factor VIIc—improved slightly, but at year 3 of the trial, differences in overall rates of coronary heart disease and stroke in the two groups were not statistically significant.² In addition, the low-fat diet intervention was associated with a reduction in blood estradiol concentrations between baseline and year 1.³ At the end of the study, however, differences in rates of breast cancer, colorectal cancer, and heart disease between the two groups were not statistically significant.

RESULTS OF DIETARY MODIFICATIONS

Fat as a percentage of total calories

At the beginning of the WHI, all participants reported consuming an average of 35% of their caloric intake from fat (Table 1). At 1 year from baseline, the fat intake decreased to 24.3% in the intervention group (short of the study goal of 20%); this level had risen again to 26.7% by year 3 and to 28.8% at the end of the study. Stratified by quartile, women who achieved the greatest reductions in saturated and trans-fatty acids or the largest increases in their intake of fruits and vegetables appeared to have a moderate reduction in the risk of coronary heart disease.² Women in the comparison group also decreased their fat intake initially, but to a lesser degree, and gradually increased it again thereafter. The mean net difference in self-reported total fat intake between the intervention group and the comparison group at 6 years was 8.2% (P < .001) (study goal, 13%).^1–3

Intake of fruits, vegetables, and grains

At baseline, fruit and vegetable intake averaged 3.6 servings per day (Table 1). In the intervention group, this increased to 5.1 servings per day at year 1, and to 5.2 servings at year 3, but at the end of the study it had decreased to 4.9 servings.

Women in the intervention group were eating 4.7 servings of grains per day at baseline. This increased to 5.1 servings at year 1 and then decreased to 4.6 servings at year 3 and to 4.3 servings at the end of the study. It seems that as the women grew older their determination to increase servings of these foods diminished.

Proponents of some currently popular diets blame weight gain on a higher intake of carbohydrates, but the women following the WHI low-fat diet did not gain weight.²

Total fat vs saturated fat

Intake of total fat and saturated fat decreased in the intervention group during the study, but the difference between fat intake in the intervention group and that in the comparison group did not reach the degree expected.

At year 1, total fat as a percentage of total caloric intake was 10.8 percentage points below that of the comparison group, whereas the study expected difference was 13.0. At the end of the trial, the difference was only 8.2 percentage points, whereas the expected difference was 11.0.

Intake of all fatty acids (saturated and unsaturated) decreased at year 1, but then went back up slightly by the end of the trial but did not exceed baseline levels, and saturated fatty acids remained well below baseline levels: 9.5% vs 12.5% of caloric intake at baseline.⁴

INTERPRETING THE RESULTS

It might be tempting to dismiss the results of the WHI dietary intervention trial as not significant and therefore not meaningful. This would be unfortunate. The trial had some remarkable accomplishments and offers important lessons for future investigations.

The initial reductions in total fat intake were impressive, and women who had the highest total fat intake at baseline achieved the greatest reduction of total fat (to less than 22% of total calories).³ Nonetheless, the dietary intervention goal of less than 20% of calories from fat was not achieved despite intensive dietary counseling and a highly motivated study population. Thus, this dietary fat target may not be reasonable in the general population.

Also, despite the absence of targeted intervention on specific fatty acids, the observed blood cholesterol levels were as expected based on the well-known formula of Mensink and Katan,¹⁴ which incorporates information on changes in saturated fat, polyunsaturated fat, and dietary cholesterol intake. The predicted reduction in low-density lipoprotein cholesterol was 2.7 mg/dL; the observed reduction was 2.3 mg/dL.² This illustrates that with greater modifications in specific known dietary risk factors for cardiovascular disease, such as saturated fatty acids, cholesterol, and unsaturated fatty acids, blood cholesterol levels respond in a predictable fashion. This was presumably not observed in WHI precisely because no goals and objectives were provided to participants for intake of saturated or polyunsaturated fatty acids.

Recent findings from the Optimal Macronutrient Intake Trial to Prevent Heart Disease (OmniHeart)¹⁵ further highlight differences in the total cholesterol response to diets of varying macronutrient (carbohydrate, protein, fat) content compared with the WHI dietary intervention.¹⁵ Participants in OmniHeart had reductions in levels of low-density lipoprotein cholesterol that were predictable from the changes reported in intake of saturated fatty acids. Presumably, the results of the WHI intervention would have been similar if the study had included this level of detail.

QUESTIONS REMAIN

Questions from the WHI that need consideration for future clinical applications include whether the study population may have already been “too old” to achieve a benefit from dietary modification, and whether the best timing for dietary intervention might be earlier adulthood with sustained changes in saturated fat, cholesterol, and unsaturated fat intake throughout life. Future subgroup analyses based on age at baseline will need to address these questions. Likewise, a longer follow-up period may be needed for a definitive evaluation of the impact of a regular low-fat diet on different health outcomes.

As reported by Patterson et al,¹⁶ the major contributors to total dietary fat intake at baseline were “added fats” such as sauces, gravies, butter, and margarines (25.1% of fat intake), followed by meats (20.9% of fat intake), and desserts (12.8% of fat intake). These findings highlight target areas for future interventions in women of this age group.

Another issue is how to standardize the dietary intervention from one clinical center to another—ie, to minimize differences in how each clinical center manages the study patients. Such differences were noted in WHI and other studies.¹⁷ Despite standardized training in delivering the dietary intervention, nutritionists encountered regional and cultural differences that required tailoring the dietary intervention to their patients’ needs. Staff turnover, an unavoidable phenomenon in long-term studies, has previously been reported to negatively influence dietary adherence.¹⁸

LIMITATIONS

A major limitation of diet modification research in general is the self-reporting of dietary intake, primarily by a food-frequency questionnaire. Although the use of a questionnaire is the most practical way to obtain dietary data for large studies, systematic biases may exist that obscure true nutrient-outcome relationships.¹⁹ Biomarker studies of energy balance suggest that people who are overweight or obese may under-report energy intake to a greater degree than people who are not overweight.²⁰ Also, we still do not know how to get people to follow a healthy diet, although theories and models abound, such as social learning and cognitive-behavioral theory, and a lack of data limits our understanding of factors related to dietary adherence.^21,22

FUTURE DIRECTIONS IN WHI

The WHI Extension Study is under way and has been funded through the year 2010. Outcomes ascertainment is the primary focus with no ongoing intervention, although the intervention group participants continue to receive a WHI newsletter that simply reiterates the importance of the study and encourages ongoing participation. As of 2006, an estimated 84% of the cohort, including both observational study and clinical trial participants, are involved. Efforts continue to recruit the remaining 16%, but many of these participants now consider themselves too old or too feeble to respond reliably.

In regard to breast cancer, the results published in 2006 are promising, albeit not statistically significant, and definitive statements cannot yet be made. However, postmenopausal women who are eating the diets highest in fat may have the greatest benefit from reductions in total fat.

Other considerations regarding the lack of statistically significant differences between groups may include the possibility that women in the intervention group may have been at lower risk for breast cancer at baseline. Likewise, although the results of the WHI dietary intervention do not include a statistically significant impact on colorectal cancer outcomes, the significant reduction in polyps and adenomas may later translate into a reduction in invasive cancer risk.

Finally, although no significant reduction was seen in the rate of death due to cardiovascular causes, greater reductions in saturated and trans-fatty acid intake were associated with greater reductions in blood cholesterol and cardiovascular risk.

Numerous subgroup analyses and ongoing assessments of the long-term impact of the diet modification are planned. Further associations are expected to emerge. The current and future results will continue to provide new insights that may lead to new clinical and public health recommendations in the future.

The WHI has raised additional issues that warrant further investigation:

• Will earlier dietary intervention, eg, during premenopausal years or even childhood, alter these results?
• Does the low-fat, high-carbohydrate diet used in WHI facilitate weight maintenance or even weight loss, as proposed by Howard et al²³?
• Do quantitative changes in physical activity and weight control attenuate morbidity and mortality rates beyond changes in diet alone?
• Do vitamin and mineral supplements or hormone therapy alter disease outcomes or quality of life?
• Which behavioral approaches are best suited to the recruitment of patients for dietary intervention trials?

More than 2 years have passed since we published the results of the Women’s Health Initiative (WHI), which caused a storm of information—and misinformation—about the effect of long-term dietary intervention on disease outcomes in postmenopausal women. Now that the dust has long settled, what have we learned from this landmark study?

The WHI results led to numerous additional analyses of all aspects of the study.^1–7 What are the implications of all the analyses to clinical practice?

In this article, we summarize key aspects of the clinical trial, including study design, interventions, main results, and future plans. We also discuss potential clinical applications and practical considerations for public health efforts.

WHO WAS ELIGIBLE, WHO WAS NOT

A total of 48,835 postmenopausal women were randomly assigned to either no dietary intervention (n = 29,294) or a dietary intervention (n = 19,541) (see below).⁷ Participants were followed at 40 clinical centers between 1993 and 2005.⁴ Their mean age was 62.3 years; 18.6% were members of minorities.

Women were eligible if they were post-menopausal and had a daily dietary fat intake of at least 32% of total calories, based on assessment via a food-frequency questionnaire. They were excluded from the study if they had any of the following: a history of breast cancer, colorectal cancer, or other cancer except skin cancer during the past 10 years; type 1 diabetes; a medical condition in which the predicted survival was less than 3 years; and a potential barrier to adherence to the study regimen, including alcoholism or a lifestyle that involved often eating meals away from home.

THE WHI DIET: LESS FAT, BUT MORE FRUITS, VEGETABLES, GRAINS

The WHI dietary intervention was designed to prevent breast cancer, based on the evidence available when the study was planned. The targets included a total fat intake of less than 20% of energy (in kilocalories), increasing the intake of fruits and vegetables to at least five servings per day, and increasing the intake of grains to at least six servings per day.

Although reduction in saturated fat intake per se was not part of the WHI protocol, we assumed from previous pilot studies⁸ that the reduction of total fat intake would simultaneously produce a reduction in saturated fat intake to 7% of total calories.

A simpler dietary intervention

Unlike the 2006 American Heart Association guidelines and the US Department of Agriculture’s Dietary Guidelines for Americans 2005, the WHI dietary intervention had no specifications for dietary fiber, specific fatty acids (trans-fatty acids, omega-3 fatty acids, conjugated linoleic acid), complex carbohydrates, whole grains, vegetable protein, or other factors that have emerged as potential risk factors for cardiovascular and other chronic diseases since the study began. The WHI intervention also included no specific recommendation for total calorie intake, nor were patients in the intervention group encouraged to lose weight, as this could have confounded the results of the dietary intervention.

Education and encouragement

Those in the intervention group were each assigned a fat-gram goal, calculated on the basis of height. They were taught how to monitor their intake of total fat, fruits, vegetables, and grains. They attended intensive behavioral modification sessions to encourage them to keep to the dietary program: 18 group sessions in the first year and quarterly maintenance sessions thereafter, touching on a wide variety of nutrition- and behavior-related topics.^7,9 Specially trained and certified nutritionists supervised the dietary intervention and the behavioral modification sessions according to the WHI study protocol.

Control-group participants received a copy of the US Department of Agriculture’s Dietary Guidelines for Americans¹⁰ and other health-related materials. They had no contact with the study nutritionists.

Other arms of the study

The WHI trial design included several arms,^4,11–13 and many participants joined more than one arm: 20,592 postmenopausal women (42.2% of the total enrollment) chose dietary modification only, 8,050 (16.5%) chose diet plus hormone replacement therapy, 25,210 (51.6%) chose diet plus calcium and vitamin D supplementation, and 5,017 (10.3%) enrolled in all three.

Length of follow-up

Participants were followed from enrollment until they died, were lost to follow-up, or requested no further contact, or until the trial’s planned completion date, regardless of adherence to the dietary intervention, according to intention-to-treat analysis. All participants were contacted by clinic staff at 6-month intervals to provide updates on their health outcomes.

Factors assessed

Height, weight, waist circumference, and blood pressure were measured at annual visits using standardized procedures. Fasting blood samples were collected at baseline and at year 1 from all participants and from a subsample of 2,816 women (5.8% of the study population) at years 3 and 6. This subsample was randomly chosen with oversampling of minority women, for whom the odds for selection were six times higher than for white women.

Physical activity was assessed at baseline and at years 1, 3, 6, and 9. Walking and participation in sports and hours of activity per week were calculated for each participant. Physical activity was expressed as metabolic equivalent tasks per week for the analyses.

A food-frequency questionnaire⁶ to assess average dietary intake in the past 3 months was given at baseline and at year 1 for all participants. A third of all participants completed the questionnaire each year in a rotating sample. Completion rates were 100% at baseline and 81% thereafter. Follow-up data were collected from years 5 through 7. Also, 4-day food records were provided by all women before randomization.

HOW OUTCOMES WERE ASSESSED

The primary assessments of clinical outcome^1–3 were mammographic screening, a self-reported medical history documented by a review of medical records, and electrocardiograms digitally obtained every 3 years. Mammograms and electrocardiograms were centrally adjudicated. The diagnosis of acute myocardial infarction was based on an algorithm that included cardiac pain, enzyme levels, and electrocardiographic readings.

OVERALL RESULTS

At 8.1 years, the incidence of breast cancer was 9% lower in the intervention group than in the comparison group (95% confidence interval [CI] = 0.83–1.01; P = .07, P = .09 weighted for length of follow-up).³ Subgroup analysis further showed that women who reported higher intakes of total dietary fat at baseline reduced their risk of breast cancer by 22% (95% CI = 0.64–0.96). Whether extended follow-up will show a significant association has yet to be determined.

Colon cancer rates did not differ between groups, but the number of polyps and adenomas reported was significantly lower in the dietary intervention group.¹ The rate of colon cancer will also be included in the extended follow-up study of the WHI.

Risk factors for coronary heart disease in both groups—including levels of serum total cholesterol and serum low-density lipoprotein cholesterol, body weight, body mass index, diastolic blood pressure, and factor VIIc—improved slightly, but at year 3 of the trial, differences in overall rates of coronary heart disease and stroke in the two groups were not statistically significant.² In addition, the low-fat diet intervention was associated with a reduction in blood estradiol concentrations between baseline and year 1.³ At the end of the study, however, differences in rates of breast cancer, colorectal cancer, and heart disease between the two groups were not statistically significant.

RESULTS OF DIETARY MODIFICATIONS

Fat as a percentage of total calories

At the beginning of the WHI, all participants reported consuming an average of 35% of their caloric intake from fat (Table 1). At 1 year from baseline, the fat intake decreased to 24.3% in the intervention group (short of the study goal of 20%); this level had risen again to 26.7% by year 3 and to 28.8% at the end of the study. Stratified by quartile, women who achieved the greatest reductions in saturated and trans-fatty acids or the largest increases in their intake of fruits and vegetables appeared to have a moderate reduction in the risk of coronary heart disease.² Women in the comparison group also decreased their fat intake initially, but to a lesser degree, and gradually increased it again thereafter. The mean net difference in self-reported total fat intake between the intervention group and the comparison group at 6 years was 8.2% (P < .001) (study goal, 13%).^1–3

Intake of fruits, vegetables, and grains

At baseline, fruit and vegetable intake averaged 3.6 servings per day (Table 1). In the intervention group, this increased to 5.1 servings per day at year 1, and to 5.2 servings at year 3, but at the end of the study it had decreased to 4.9 servings.

Women in the intervention group were eating 4.7 servings of grains per day at baseline. This increased to 5.1 servings at year 1 and then decreased to 4.6 servings at year 3 and to 4.3 servings at the end of the study. It seems that as the women grew older their determination to increase servings of these foods diminished.

Proponents of some currently popular diets blame weight gain on a higher intake of carbohydrates, but the women following the WHI low-fat diet did not gain weight.²

Total fat vs saturated fat

Intake of total fat and saturated fat decreased in the intervention group during the study, but the difference between fat intake in the intervention group and that in the comparison group did not reach the degree expected.

At year 1, total fat as a percentage of total caloric intake was 10.8 percentage points below that of the comparison group, whereas the study expected difference was 13.0. At the end of the trial, the difference was only 8.2 percentage points, whereas the expected difference was 11.0.

Intake of all fatty acids (saturated and unsaturated) decreased at year 1, but then went back up slightly by the end of the trial but did not exceed baseline levels, and saturated fatty acids remained well below baseline levels: 9.5% vs 12.5% of caloric intake at baseline.⁴

INTERPRETING THE RESULTS

It might be tempting to dismiss the results of the WHI dietary intervention trial as not significant and therefore not meaningful. This would be unfortunate. The trial had some remarkable accomplishments and offers important lessons for future investigations.

The initial reductions in total fat intake were impressive, and women who had the highest total fat intake at baseline achieved the greatest reduction of total fat (to less than 22% of total calories).³ Nonetheless, the dietary intervention goal of less than 20% of calories from fat was not achieved despite intensive dietary counseling and a highly motivated study population. Thus, this dietary fat target may not be reasonable in the general population.

Also, despite the absence of targeted intervention on specific fatty acids, the observed blood cholesterol levels were as expected based on the well-known formula of Mensink and Katan,¹⁴ which incorporates information on changes in saturated fat, polyunsaturated fat, and dietary cholesterol intake. The predicted reduction in low-density lipoprotein cholesterol was 2.7 mg/dL; the observed reduction was 2.3 mg/dL.² This illustrates that with greater modifications in specific known dietary risk factors for cardiovascular disease, such as saturated fatty acids, cholesterol, and unsaturated fatty acids, blood cholesterol levels respond in a predictable fashion. This was presumably not observed in WHI precisely because no goals and objectives were provided to participants for intake of saturated or polyunsaturated fatty acids.

Recent findings from the Optimal Macronutrient Intake Trial to Prevent Heart Disease (OmniHeart)¹⁵ further highlight differences in the total cholesterol response to diets of varying macronutrient (carbohydrate, protein, fat) content compared with the WHI dietary intervention.¹⁵ Participants in OmniHeart had reductions in levels of low-density lipoprotein cholesterol that were predictable from the changes reported in intake of saturated fatty acids. Presumably, the results of the WHI intervention would have been similar if the study had included this level of detail.

QUESTIONS REMAIN

Questions from the WHI that need consideration for future clinical applications include whether the study population may have already been “too old” to achieve a benefit from dietary modification, and whether the best timing for dietary intervention might be earlier adulthood with sustained changes in saturated fat, cholesterol, and unsaturated fat intake throughout life. Future subgroup analyses based on age at baseline will need to address these questions. Likewise, a longer follow-up period may be needed for a definitive evaluation of the impact of a regular low-fat diet on different health outcomes.

As reported by Patterson et al,¹⁶ the major contributors to total dietary fat intake at baseline were “added fats” such as sauces, gravies, butter, and margarines (25.1% of fat intake), followed by meats (20.9% of fat intake), and desserts (12.8% of fat intake). These findings highlight target areas for future interventions in women of this age group.

Another issue is how to standardize the dietary intervention from one clinical center to another—ie, to minimize differences in how each clinical center manages the study patients. Such differences were noted in WHI and other studies.¹⁷ Despite standardized training in delivering the dietary intervention, nutritionists encountered regional and cultural differences that required tailoring the dietary intervention to their patients’ needs. Staff turnover, an unavoidable phenomenon in long-term studies, has previously been reported to negatively influence dietary adherence.¹⁸

LIMITATIONS

A major limitation of diet modification research in general is the self-reporting of dietary intake, primarily by a food-frequency questionnaire. Although the use of a questionnaire is the most practical way to obtain dietary data for large studies, systematic biases may exist that obscure true nutrient-outcome relationships.¹⁹ Biomarker studies of energy balance suggest that people who are overweight or obese may under-report energy intake to a greater degree than people who are not overweight.²⁰ Also, we still do not know how to get people to follow a healthy diet, although theories and models abound, such as social learning and cognitive-behavioral theory, and a lack of data limits our understanding of factors related to dietary adherence.^21,22

FUTURE DIRECTIONS IN WHI

The WHI Extension Study is under way and has been funded through the year 2010. Outcomes ascertainment is the primary focus with no ongoing intervention, although the intervention group participants continue to receive a WHI newsletter that simply reiterates the importance of the study and encourages ongoing participation. As of 2006, an estimated 84% of the cohort, including both observational study and clinical trial participants, are involved. Efforts continue to recruit the remaining 16%, but many of these participants now consider themselves too old or too feeble to respond reliably.

In regard to breast cancer, the results published in 2006 are promising, albeit not statistically significant, and definitive statements cannot yet be made. However, postmenopausal women who are eating the diets highest in fat may have the greatest benefit from reductions in total fat.

Other considerations regarding the lack of statistically significant differences between groups may include the possibility that women in the intervention group may have been at lower risk for breast cancer at baseline. Likewise, although the results of the WHI dietary intervention do not include a statistically significant impact on colorectal cancer outcomes, the significant reduction in polyps and adenomas may later translate into a reduction in invasive cancer risk.

Finally, although no significant reduction was seen in the rate of death due to cardiovascular causes, greater reductions in saturated and trans-fatty acid intake were associated with greater reductions in blood cholesterol and cardiovascular risk.

Numerous subgroup analyses and ongoing assessments of the long-term impact of the diet modification are planned. Further associations are expected to emerge. The current and future results will continue to provide new insights that may lead to new clinical and public health recommendations in the future.

The WHI has raised additional issues that warrant further investigation:

• Will earlier dietary intervention, eg, during premenopausal years or even childhood, alter these results?
• Does the low-fat, high-carbohydrate diet used in WHI facilitate weight maintenance or even weight loss, as proposed by Howard et al²³?
• Do quantitative changes in physical activity and weight control attenuate morbidity and mortality rates beyond changes in diet alone?
• Do vitamin and mineral supplements or hormone therapy alter disease outcomes or quality of life?
• Which behavioral approaches are best suited to the recruitment of patients for dietary intervention trials?

More than 2 years have passed since we published the results of the Women’s Health Initiative (WHI), which caused a storm of information—and misinformation—about the effect of long-term dietary intervention on disease outcomes in postmenopausal women. Now that the dust has long settled, what have we learned from this landmark study?

The WHI results led to numerous additional analyses of all aspects of the study.^1–7 What are the implications of all the analyses to clinical practice?

In this article, we summarize key aspects of the clinical trial, including study design, interventions, main results, and future plans. We also discuss potential clinical applications and practical considerations for public health efforts.

WHO WAS ELIGIBLE, WHO WAS NOT

A total of 48,835 postmenopausal women were randomly assigned to either no dietary intervention (n = 29,294) or a dietary intervention (n = 19,541) (see below).⁷ Participants were followed at 40 clinical centers between 1993 and 2005.⁴ Their mean age was 62.3 years; 18.6% were members of minorities.

Women were eligible if they were post-menopausal and had a daily dietary fat intake of at least 32% of total calories, based on assessment via a food-frequency questionnaire. They were excluded from the study if they had any of the following: a history of breast cancer, colorectal cancer, or other cancer except skin cancer during the past 10 years; type 1 diabetes; a medical condition in which the predicted survival was less than 3 years; and a potential barrier to adherence to the study regimen, including alcoholism or a lifestyle that involved often eating meals away from home.

THE WHI DIET: LESS FAT, BUT MORE FRUITS, VEGETABLES, GRAINS

The WHI dietary intervention was designed to prevent breast cancer, based on the evidence available when the study was planned. The targets included a total fat intake of less than 20% of energy (in kilocalories), increasing the intake of fruits and vegetables to at least five servings per day, and increasing the intake of grains to at least six servings per day.

Although reduction in saturated fat intake per se was not part of the WHI protocol, we assumed from previous pilot studies⁸ that the reduction of total fat intake would simultaneously produce a reduction in saturated fat intake to 7% of total calories.

A simpler dietary intervention

Unlike the 2006 American Heart Association guidelines and the US Department of Agriculture’s Dietary Guidelines for Americans 2005, the WHI dietary intervention had no specifications for dietary fiber, specific fatty acids (trans-fatty acids, omega-3 fatty acids, conjugated linoleic acid), complex carbohydrates, whole grains, vegetable protein, or other factors that have emerged as potential risk factors for cardiovascular and other chronic diseases since the study began. The WHI intervention also included no specific recommendation for total calorie intake, nor were patients in the intervention group encouraged to lose weight, as this could have confounded the results of the dietary intervention.

Education and encouragement

Those in the intervention group were each assigned a fat-gram goal, calculated on the basis of height. They were taught how to monitor their intake of total fat, fruits, vegetables, and grains. They attended intensive behavioral modification sessions to encourage them to keep to the dietary program: 18 group sessions in the first year and quarterly maintenance sessions thereafter, touching on a wide variety of nutrition- and behavior-related topics.^7,9 Specially trained and certified nutritionists supervised the dietary intervention and the behavioral modification sessions according to the WHI study protocol.

Control-group participants received a copy of the US Department of Agriculture’s Dietary Guidelines for Americans¹⁰ and other health-related materials. They had no contact with the study nutritionists.

Other arms of the study

The WHI trial design included several arms,^4,11–13 and many participants joined more than one arm: 20,592 postmenopausal women (42.2% of the total enrollment) chose dietary modification only, 8,050 (16.5%) chose diet plus hormone replacement therapy, 25,210 (51.6%) chose diet plus calcium and vitamin D supplementation, and 5,017 (10.3%) enrolled in all three.

Length of follow-up

Participants were followed from enrollment until they died, were lost to follow-up, or requested no further contact, or until the trial’s planned completion date, regardless of adherence to the dietary intervention, according to intention-to-treat analysis. All participants were contacted by clinic staff at 6-month intervals to provide updates on their health outcomes.

Factors assessed

Height, weight, waist circumference, and blood pressure were measured at annual visits using standardized procedures. Fasting blood samples were collected at baseline and at year 1 from all participants and from a subsample of 2,816 women (5.8% of the study population) at years 3 and 6. This subsample was randomly chosen with oversampling of minority women, for whom the odds for selection were six times higher than for white women.

Physical activity was assessed at baseline and at years 1, 3, 6, and 9. Walking and participation in sports and hours of activity per week were calculated for each participant. Physical activity was expressed as metabolic equivalent tasks per week for the analyses.

A food-frequency questionnaire⁶ to assess average dietary intake in the past 3 months was given at baseline and at year 1 for all participants. A third of all participants completed the questionnaire each year in a rotating sample. Completion rates were 100% at baseline and 81% thereafter. Follow-up data were collected from years 5 through 7. Also, 4-day food records were provided by all women before randomization.

HOW OUTCOMES WERE ASSESSED

The primary assessments of clinical outcome^1–3 were mammographic screening, a self-reported medical history documented by a review of medical records, and electrocardiograms digitally obtained every 3 years. Mammograms and electrocardiograms were centrally adjudicated. The diagnosis of acute myocardial infarction was based on an algorithm that included cardiac pain, enzyme levels, and electrocardiographic readings.

OVERALL RESULTS

At 8.1 years, the incidence of breast cancer was 9% lower in the intervention group than in the comparison group (95% confidence interval [CI] = 0.83–1.01; P = .07, P = .09 weighted for length of follow-up).³ Subgroup analysis further showed that women who reported higher intakes of total dietary fat at baseline reduced their risk of breast cancer by 22% (95% CI = 0.64–0.96). Whether extended follow-up will show a significant association has yet to be determined.

Colon cancer rates did not differ between groups, but the number of polyps and adenomas reported was significantly lower in the dietary intervention group.¹ The rate of colon cancer will also be included in the extended follow-up study of the WHI.

Risk factors for coronary heart disease in both groups—including levels of serum total cholesterol and serum low-density lipoprotein cholesterol, body weight, body mass index, diastolic blood pressure, and factor VIIc—improved slightly, but at year 3 of the trial, differences in overall rates of coronary heart disease and stroke in the two groups were not statistically significant.² In addition, the low-fat diet intervention was associated with a reduction in blood estradiol concentrations between baseline and year 1.³ At the end of the study, however, differences in rates of breast cancer, colorectal cancer, and heart disease between the two groups were not statistically significant.

RESULTS OF DIETARY MODIFICATIONS

Fat as a percentage of total calories

At the beginning of the WHI, all participants reported consuming an average of 35% of their caloric intake from fat (Table 1). At 1 year from baseline, the fat intake decreased to 24.3% in the intervention group (short of the study goal of 20%); this level had risen again to 26.7% by year 3 and to 28.8% at the end of the study. Stratified by quartile, women who achieved the greatest reductions in saturated and trans-fatty acids or the largest increases in their intake of fruits and vegetables appeared to have a moderate reduction in the risk of coronary heart disease.² Women in the comparison group also decreased their fat intake initially, but to a lesser degree, and gradually increased it again thereafter. The mean net difference in self-reported total fat intake between the intervention group and the comparison group at 6 years was 8.2% (P < .001) (study goal, 13%).^1–3

Intake of fruits, vegetables, and grains

At baseline, fruit and vegetable intake averaged 3.6 servings per day (Table 1). In the intervention group, this increased to 5.1 servings per day at year 1, and to 5.2 servings at year 3, but at the end of the study it had decreased to 4.9 servings.

Women in the intervention group were eating 4.7 servings of grains per day at baseline. This increased to 5.1 servings at year 1 and then decreased to 4.6 servings at year 3 and to 4.3 servings at the end of the study. It seems that as the women grew older their determination to increase servings of these foods diminished.

Proponents of some currently popular diets blame weight gain on a higher intake of carbohydrates, but the women following the WHI low-fat diet did not gain weight.²

Total fat vs saturated fat

Intake of total fat and saturated fat decreased in the intervention group during the study, but the difference between fat intake in the intervention group and that in the comparison group did not reach the degree expected.

At year 1, total fat as a percentage of total caloric intake was 10.8 percentage points below that of the comparison group, whereas the study expected difference was 13.0. At the end of the trial, the difference was only 8.2 percentage points, whereas the expected difference was 11.0.

Intake of all fatty acids (saturated and unsaturated) decreased at year 1, but then went back up slightly by the end of the trial but did not exceed baseline levels, and saturated fatty acids remained well below baseline levels: 9.5% vs 12.5% of caloric intake at baseline.⁴

INTERPRETING THE RESULTS

It might be tempting to dismiss the results of the WHI dietary intervention trial as not significant and therefore not meaningful. This would be unfortunate. The trial had some remarkable accomplishments and offers important lessons for future investigations.

The initial reductions in total fat intake were impressive, and women who had the highest total fat intake at baseline achieved the greatest reduction of total fat (to less than 22% of total calories).³ Nonetheless, the dietary intervention goal of less than 20% of calories from fat was not achieved despite intensive dietary counseling and a highly motivated study population. Thus, this dietary fat target may not be reasonable in the general population.

Also, despite the absence of targeted intervention on specific fatty acids, the observed blood cholesterol levels were as expected based on the well-known formula of Mensink and Katan,¹⁴ which incorporates information on changes in saturated fat, polyunsaturated fat, and dietary cholesterol intake. The predicted reduction in low-density lipoprotein cholesterol was 2.7 mg/dL; the observed reduction was 2.3 mg/dL.² This illustrates that with greater modifications in specific known dietary risk factors for cardiovascular disease, such as saturated fatty acids, cholesterol, and unsaturated fatty acids, blood cholesterol levels respond in a predictable fashion. This was presumably not observed in WHI precisely because no goals and objectives were provided to participants for intake of saturated or polyunsaturated fatty acids.

Recent findings from the Optimal Macronutrient Intake Trial to Prevent Heart Disease (OmniHeart)¹⁵ further highlight differences in the total cholesterol response to diets of varying macronutrient (carbohydrate, protein, fat) content compared with the WHI dietary intervention.¹⁵ Participants in OmniHeart had reductions in levels of low-density lipoprotein cholesterol that were predictable from the changes reported in intake of saturated fatty acids. Presumably, the results of the WHI intervention would have been similar if the study had included this level of detail.

QUESTIONS REMAIN

Questions from the WHI that need consideration for future clinical applications include whether the study population may have already been “too old” to achieve a benefit from dietary modification, and whether the best timing for dietary intervention might be earlier adulthood with sustained changes in saturated fat, cholesterol, and unsaturated fat intake throughout life. Future subgroup analyses based on age at baseline will need to address these questions. Likewise, a longer follow-up period may be needed for a definitive evaluation of the impact of a regular low-fat diet on different health outcomes.

As reported by Patterson et al,¹⁶ the major contributors to total dietary fat intake at baseline were “added fats” such as sauces, gravies, butter, and margarines (25.1% of fat intake), followed by meats (20.9% of fat intake), and desserts (12.8% of fat intake). These findings highlight target areas for future interventions in women of this age group.

Another issue is how to standardize the dietary intervention from one clinical center to another—ie, to minimize differences in how each clinical center manages the study patients. Such differences were noted in WHI and other studies.¹⁷ Despite standardized training in delivering the dietary intervention, nutritionists encountered regional and cultural differences that required tailoring the dietary intervention to their patients’ needs. Staff turnover, an unavoidable phenomenon in long-term studies, has previously been reported to negatively influence dietary adherence.¹⁸

LIMITATIONS

A major limitation of diet modification research in general is the self-reporting of dietary intake, primarily by a food-frequency questionnaire. Although the use of a questionnaire is the most practical way to obtain dietary data for large studies, systematic biases may exist that obscure true nutrient-outcome relationships.¹⁹ Biomarker studies of energy balance suggest that people who are overweight or obese may under-report energy intake to a greater degree than people who are not overweight.²⁰ Also, we still do not know how to get people to follow a healthy diet, although theories and models abound, such as social learning and cognitive-behavioral theory, and a lack of data limits our understanding of factors related to dietary adherence.^21,22

FUTURE DIRECTIONS IN WHI

The WHI Extension Study is under way and has been funded through the year 2010. Outcomes ascertainment is the primary focus with no ongoing intervention, although the intervention group participants continue to receive a WHI newsletter that simply reiterates the importance of the study and encourages ongoing participation. As of 2006, an estimated 84% of the cohort, including both observational study and clinical trial participants, are involved. Efforts continue to recruit the remaining 16%, but many of these participants now consider themselves too old or too feeble to respond reliably.

In regard to breast cancer, the results published in 2006 are promising, albeit not statistically significant, and definitive statements cannot yet be made. However, postmenopausal women who are eating the diets highest in fat may have the greatest benefit from reductions in total fat.

Other considerations regarding the lack of statistically significant differences between groups may include the possibility that women in the intervention group may have been at lower risk for breast cancer at baseline. Likewise, although the results of the WHI dietary intervention do not include a statistically significant impact on colorectal cancer outcomes, the significant reduction in polyps and adenomas may later translate into a reduction in invasive cancer risk.

Finally, although no significant reduction was seen in the rate of death due to cardiovascular causes, greater reductions in saturated and trans-fatty acid intake were associated with greater reductions in blood cholesterol and cardiovascular risk.

Numerous subgroup analyses and ongoing assessments of the long-term impact of the diet modification are planned. Further associations are expected to emerge. The current and future results will continue to provide new insights that may lead to new clinical and public health recommendations in the future.

The WHI has raised additional issues that warrant further investigation:

• Will earlier dietary intervention, eg, during premenopausal years or even childhood, alter these results?
• Does the low-fat, high-carbohydrate diet used in WHI facilitate weight maintenance or even weight loss, as proposed by Howard et al²³?
• Do quantitative changes in physical activity and weight control attenuate morbidity and mortality rates beyond changes in diet alone?
• Do vitamin and mineral supplements or hormone therapy alter disease outcomes or quality of life?
• Which behavioral approaches are best suited to the recruitment of patients for dietary intervention trials?

Radiography plays a key role in the initial evaluation of acute knee pain in adults. Yet conflicting studies and the absence of clear guidelines may leave the primary care physician uncertain as to which imaging test to order—ie, whether radiography is sufficient, and when computed tomography (CT) or magnetic resonance imaging (MRI) is needed. This article reviews the indications for radiologic examination of the knee and discusses indications for cross-sectional imaging studies. Imaging in oncology patients is not discussed here.

ACUTE KNEE PAIN: A TYPICAL SCENARIO

A 47-year-old woman presents to the emergency department with left knee pain after a motor vehicle accident that occurred the day before. The car she was driving hit a tree, and she hit her knee on the dashboard. She was wearing a seatbelt at the time of the accident. She says she was unable to walk immediately after the accident because of knee pain.

The initial examination in the emergency room reveals swelling and pain throughout the range of motion. The anterior drawer test and the Lachman test are negative (see below).

The patient is discharged home with a knee immobilizer, pain medication, and crutches, with instructions for a follow-up visit in the orthopedics clinic.

Five days later, she returns to the emergency department complaining of continuing knee pain. She says the knee gives way when she puts weight on it. The physical findings are unchanged, and she is discharged home with a follow-up appointment with orthopedics in 3 days.

At the follow-up visit, she complains of persistent knee pain in the medial aspect of the knee joint. Physical examination is difficult because of pain and swelling, and it reveals mild joint effusion with no gross instability. She has pain on the medial side with valgus stress, but there appears to be a hard end point. There is no posterior sag, and the Lachman test is negative.

Based on the physical examination and the patient’s complaints, she receives a diagnosis of medial collateral ligament strain and injury. She is given a hinged brace and is instructed to undergo a physical rehabilitation program.

Three weeks after the initial evaluation, she returns to the orthopedics clinic with continuing knee problems. Mild knee effusion persists, but she has less pain and swelling, allowing a more complete examination. The examination reveals less limitation of range of motion and a hint of positivity on the Lachman test. The knee is diffusely tender, and the pain seems out of proportion with the maneuvers used during the examination. She requests more pain medication. You suspect internal derangement of the knee. Which imaging test should you order to further evaluate this patient?

A SYSTEMATIC AND COST-EFFECTIVE APPROACH IS NEEDED

The case presented above represents a typical scenario for the presentation of acute knee pain and illustrates the diagnostic challenges.

Knee pain is a common reason for emergency room visits, and it accounts for approximately 1.9 million visits to primary care clinics annually.¹ In the emergency department, most patients undergo plain radiography to assess for fracture, yet approximately 92% of radiographic studies do not show a fracture.² Clearly, the evaluation of knee pain requires a systematic, accurate, and cost-effective approach.

Key elements of the physical examination

In acute knee pain, accurate diagnosis begins with a detailed history and physical examination.

The anterior drawer test is done to evaluate the anterior cruciate ligament. With the relaxed knee flexed to approximately 80° and the foot stabilized in a neutral position, the examiner grasps the proximal tibia in a firm yet gentle grip, and then applies anterior force, noting the degree of anterior displacement compared with the other knee.

The Lachman test, a variation of the anterior drawer test, is more definitive for the anterior cruciate ligament and is carried out with the knee in 15° of flexion and external rotation, in order to relax the iliotibial band. The upper hand grasps the distal thigh, and the lower hand, with the thumb on the tibial tubercle, pulls the tibia forward. The degree of anterior motion in millimeters is noted and compared with that on the other side, and the end point is graded as “soft” or “hard.” An end point is considered hard when a ligament abruptly halts the motion of the bone being tested against the stabilized bone. An end point is considered soft when the ligament is disrupted and the restraints are the more elastic secondary stabilizers.

Debate continues

Some authors contend that in skilled hands a thorough history, physical examination, and radiographic examination are sufficient to diagnose trauma-related intra-articular knee disorders.³ Others contend that MRI plays a key role in the initial evaluation. A number of studies^4–8 have shown that using MRI in the initial evaluation not only identifies key lesions, but also may eliminate the need for an invasive diagnostic procedure (ie, arthroscopy).

For example, MRI can reveal fracture, stress fracture, insufficiency fracture, and transient patellar dislocation—conditions that may satisfactorily explain knee symptoms.

PLAIN RADIOGRAPHY STILL THE FIRST STEP IN KNEE EVALUATION

Radiography is the first step in the evaluation of knee pain. It is quick and inexpensive and can yield many diagnostic clues. It can readily reveal fractures, osteochondral defects, bony lesions, joint effusions, joint space narrowing, and bone misalignment.

In patients with knee trauma, supine anteroposterior and cross-table lateral radiographic images are generally obtained. In patients whose knee pain is not due to trauma, standing projections are done, as well as dedicated projection of the patellofemoral articulation. A standing series is most helpful for evaluating joint space and alignment.

Applying the Ottawa rules

When a patient presents to the emergency room with acute knee pain, the immediate concern is whether he or she has a fracture. The Ottawa knee rules⁹ for when to order radiography in adults with knee pain are highly sensitive for detecting a clinically important fracture. If any one of the five Ottawa criteria applies—ie, the patient is age 55 or older, has tenderness at the head of the fibula, has patellar tenderness, is unable to flex the knee to 90°, or is unable to bear weight—then radiography is indicated.

While studies have validated the ability of the Ottawa rules to detect important fractures in acute knee injury,²,¹⁰ fracture is the cause of only a small percentage of knee complaints in the primary care setting. More common causes include osteoarthritis, meniscal injury, ligamental injury, and crystal arthropathy, and these account for approximately half of all diagnoses. Sprain and strain account for most of the rest of knee injuries.¹

Acute exacerbations of osteoarthritis

Osteoarthritis is a chronic problem, yet it is not unusual for a patient to present to the primary care physician with an acute exacerbation of joint pain. The clinical hallmarks include age over 50, stiffness lasting less than 30 minutes, bony enlargement and tenderness, and crepitus. The radiographic hallmarks, according to the Kellgren-Lawrence grading scale, are joint space narrowing, osteophytes, subchondral cysts, and sclerosis. These radiographic findings correlate well with clinical findings in these patients.¹¹

Situations in which radiography is less helpful

In some cases the radiographic findings may not explain the patient’s clinical signs and symptoms. For example, in suspected crystalline and septic arthritis, the clinical presentation may include warmth, erythema, and effusion. Arthrocentesis would be indicated in such a patient. Indeed, in the case of suspected pseudogout, chondrocalcinosis may be radiographically evident. However, it is also present in many patients without symptoms or with osteoarthritis, so radiographic evidence does not provide a definite diagnosis.

While radiography may not always identify the cause of knee pain, it is useful in excluding serious problems such as fractures, advanced degenerative changes, and neoplasms, and it may help direct further management. Radiography is not useful in the evaluation of the cruciate and collateral ligaments, the menisci, and the hyaline cartilage of the knee and may fail to show an insufficiency or stress fracture. To evaluate these structures and associated soft tissues, MRI is preferable.

COMPUTED TOMOGRAPHY IN ACUTE KNEE PAIN

CURRENT USES OF MRI TO EVALUATE ACUTE KNEE PAIN

As mentioned above, MRI is useful in evaluating suspected meniscal and ligamentous injuries.

Figure 3 shows how T2-weighted MRI was used to evaluate for suspected meniscal injury in our 47-year-old female patient with left knee pain after a motor vehicle accident.

Still a matter of debate

MRI’s role in the diagnosis of knee pain is still a contentious issue.

Advantages of MRI are that it is noninvasive, it does not use ionizing radiation, it gives multiplanar images, and it provides images of soft-tissue structures, which other imaging methods cannot.¹² It is a well-proven and widely accepted test. Its sensitivity for detecting meniscal and cruciate ligament injury ranges from 75% to 88%,¹ and it can help in the evaluation of other injuries for which radiography is not useful, including synovitis, bone bruise, stress or insufficiency fracture, osteochondral defects, and osteonecrosis.

In addition, several studies show that using MRI to establish the diagnosis in acute knee pain can mean that 22% to 42% fewer arthroscopic procedures need to be performed.^4–8 Authors of a prospective double-blind study⁸ recommended that MRI be used in patients with acute knee injury when the findings of the clinical history and examination by orthopedic surgeons prove equivocal.⁸ MRI evaluation is especially desirable for young, active patients who wish to resume activity as soon as possible.

A routine MRI examination consists of T1- and T2-weighted images in three planes, although the number of sequences and planes varies from hospital to hospital. The use of gadolinium contrast is indicated only when osteomyelitis, septic arthritis, or a mass is suspected.

Disadvantages of MRI include its cost: Medicare reimbursement for knee MRI is around $400, compared with $200 for knee CT and $50 for knee radiography with four views. Also, while studies have shown MRI to have a high sensitivity and specificity in the diagnosis of acute knee injury, some have reported a high false-positive rate for the detection of meniscal tear.¹³,¹⁴ MRI has also been shown to have a lower sensitivity than arthroscopy for lesions of the articular cartilage.¹³ Furthermore, MRI has been shown to reveal cartilage lesions, osteophytes, and meniscal abnormalities in asymptomatic study volunteers with no history of pain, trauma or knee disease.¹⁴ Therefore, findings on MRI must closely correlate with findings on the history and physical examination.

Additional indications for knee MRI

Cartilage can be assessed on routine MRI sequences of the knee. Since closed MRI systems have more powerful magnets than open systems, closed MRI systems provide greater anatomic detail.

MRI can identify other lesions, such as spontaneous osteonecrosis of the knee, usually seen in elderly women who may present with sudden knee pain. In such patients, MRI findings of focal replacement of the bone marrow and surrounding edema are specific for osteonecrosis.

Opinions vary as to whether bone marrow edema is always associated with pain. Sequential MRI studies have shown persistence of bone marrow edema for 2 years in patients with degenerative arthritis whose symptoms have waned. Bone marrow edema may be associated with pain but may be absent or inconsequential in the presence of pain.

Because fluid-sensitive T2-weighted MRI is exquisitely sensitive for mobile water protons (ie, in bone marrow edema), it is important that a cause for the edema-like signal be sought on the MRI scan, since this finding is nonspecific and may be associated with articular disease, trauma, osteonecrosis, infection, or bone tumors. Additionally, clinicians need to be aware that the findings on MRI depend on the quality of the study, and are influenced by technical factors such as magnet strength, imaging planes, and use of surface coils.

MRI should be used in patients in whom surgical treatment, ie, arthroscopy, is being considered. As discussed above, several studies have shown that a significant number of unnecessary arthroscopies may be prevented when preceded by an MRI examination.

Figure 5 shows the use of MRI in the evaluation of a 45-year-old man with left knee pain after a motorcycle accident.

ULTRASONOGRAPHY HAS ONLY A LIMITED ROLE

Ultrasonography does not play a major role in the evaluation of acute knee pain in the United States, in part because the accuracy of the results depend much on the technical skills and experience of the operator.

Ultrasonography can be useful in evaluating for rupture of the quadriceps and patellar tendon, or to assess a repaired tendon after surgery,¹⁵ and it is a quick and reliable way to determine the presence of joint effusion and popliteal cyst. It is also used to guide needle placement for joint aspiration and injection.

Radiography plays a key role in the initial evaluation of acute knee pain in adults. Yet conflicting studies and the absence of clear guidelines may leave the primary care physician uncertain as to which imaging test to order—ie, whether radiography is sufficient, and when computed tomography (CT) or magnetic resonance imaging (MRI) is needed. This article reviews the indications for radiologic examination of the knee and discusses indications for cross-sectional imaging studies. Imaging in oncology patients is not discussed here.

ACUTE KNEE PAIN: A TYPICAL SCENARIO

A 47-year-old woman presents to the emergency department with left knee pain after a motor vehicle accident that occurred the day before. The car she was driving hit a tree, and she hit her knee on the dashboard. She was wearing a seatbelt at the time of the accident. She says she was unable to walk immediately after the accident because of knee pain.

The initial examination in the emergency room reveals swelling and pain throughout the range of motion. The anterior drawer test and the Lachman test are negative (see below).

The patient is discharged home with a knee immobilizer, pain medication, and crutches, with instructions for a follow-up visit in the orthopedics clinic.

Five days later, she returns to the emergency department complaining of continuing knee pain. She says the knee gives way when she puts weight on it. The physical findings are unchanged, and she is discharged home with a follow-up appointment with orthopedics in 3 days.

At the follow-up visit, she complains of persistent knee pain in the medial aspect of the knee joint. Physical examination is difficult because of pain and swelling, and it reveals mild joint effusion with no gross instability. She has pain on the medial side with valgus stress, but there appears to be a hard end point. There is no posterior sag, and the Lachman test is negative.

Based on the physical examination and the patient’s complaints, she receives a diagnosis of medial collateral ligament strain and injury. She is given a hinged brace and is instructed to undergo a physical rehabilitation program.

Three weeks after the initial evaluation, she returns to the orthopedics clinic with continuing knee problems. Mild knee effusion persists, but she has less pain and swelling, allowing a more complete examination. The examination reveals less limitation of range of motion and a hint of positivity on the Lachman test. The knee is diffusely tender, and the pain seems out of proportion with the maneuvers used during the examination. She requests more pain medication. You suspect internal derangement of the knee. Which imaging test should you order to further evaluate this patient?

A SYSTEMATIC AND COST-EFFECTIVE APPROACH IS NEEDED

The case presented above represents a typical scenario for the presentation of acute knee pain and illustrates the diagnostic challenges.

Knee pain is a common reason for emergency room visits, and it accounts for approximately 1.9 million visits to primary care clinics annually.¹ In the emergency department, most patients undergo plain radiography to assess for fracture, yet approximately 92% of radiographic studies do not show a fracture.² Clearly, the evaluation of knee pain requires a systematic, accurate, and cost-effective approach.

Key elements of the physical examination

In acute knee pain, accurate diagnosis begins with a detailed history and physical examination.

The anterior drawer test is done to evaluate the anterior cruciate ligament. With the relaxed knee flexed to approximately 80° and the foot stabilized in a neutral position, the examiner grasps the proximal tibia in a firm yet gentle grip, and then applies anterior force, noting the degree of anterior displacement compared with the other knee.

The Lachman test, a variation of the anterior drawer test, is more definitive for the anterior cruciate ligament and is carried out with the knee in 15° of flexion and external rotation, in order to relax the iliotibial band. The upper hand grasps the distal thigh, and the lower hand, with the thumb on the tibial tubercle, pulls the tibia forward. The degree of anterior motion in millimeters is noted and compared with that on the other side, and the end point is graded as “soft” or “hard.” An end point is considered hard when a ligament abruptly halts the motion of the bone being tested against the stabilized bone. An end point is considered soft when the ligament is disrupted and the restraints are the more elastic secondary stabilizers.

Debate continues

Some authors contend that in skilled hands a thorough history, physical examination, and radiographic examination are sufficient to diagnose trauma-related intra-articular knee disorders.³ Others contend that MRI plays a key role in the initial evaluation. A number of studies^4–8 have shown that using MRI in the initial evaluation not only identifies key lesions, but also may eliminate the need for an invasive diagnostic procedure (ie, arthroscopy).

For example, MRI can reveal fracture, stress fracture, insufficiency fracture, and transient patellar dislocation—conditions that may satisfactorily explain knee symptoms.

PLAIN RADIOGRAPHY STILL THE FIRST STEP IN KNEE EVALUATION

Radiography is the first step in the evaluation of knee pain. It is quick and inexpensive and can yield many diagnostic clues. It can readily reveal fractures, osteochondral defects, bony lesions, joint effusions, joint space narrowing, and bone misalignment.

In patients with knee trauma, supine anteroposterior and cross-table lateral radiographic images are generally obtained. In patients whose knee pain is not due to trauma, standing projections are done, as well as dedicated projection of the patellofemoral articulation. A standing series is most helpful for evaluating joint space and alignment.

Applying the Ottawa rules

When a patient presents to the emergency room with acute knee pain, the immediate concern is whether he or she has a fracture. The Ottawa knee rules⁹ for when to order radiography in adults with knee pain are highly sensitive for detecting a clinically important fracture. If any one of the five Ottawa criteria applies—ie, the patient is age 55 or older, has tenderness at the head of the fibula, has patellar tenderness, is unable to flex the knee to 90°, or is unable to bear weight—then radiography is indicated.

While studies have validated the ability of the Ottawa rules to detect important fractures in acute knee injury,²,¹⁰ fracture is the cause of only a small percentage of knee complaints in the primary care setting. More common causes include osteoarthritis, meniscal injury, ligamental injury, and crystal arthropathy, and these account for approximately half of all diagnoses. Sprain and strain account for most of the rest of knee injuries.¹

Acute exacerbations of osteoarthritis

Osteoarthritis is a chronic problem, yet it is not unusual for a patient to present to the primary care physician with an acute exacerbation of joint pain. The clinical hallmarks include age over 50, stiffness lasting less than 30 minutes, bony enlargement and tenderness, and crepitus. The radiographic hallmarks, according to the Kellgren-Lawrence grading scale, are joint space narrowing, osteophytes, subchondral cysts, and sclerosis. These radiographic findings correlate well with clinical findings in these patients.¹¹

Situations in which radiography is less helpful

In some cases the radiographic findings may not explain the patient’s clinical signs and symptoms. For example, in suspected crystalline and septic arthritis, the clinical presentation may include warmth, erythema, and effusion. Arthrocentesis would be indicated in such a patient. Indeed, in the case of suspected pseudogout, chondrocalcinosis may be radiographically evident. However, it is also present in many patients without symptoms or with osteoarthritis, so radiographic evidence does not provide a definite diagnosis.

While radiography may not always identify the cause of knee pain, it is useful in excluding serious problems such as fractures, advanced degenerative changes, and neoplasms, and it may help direct further management. Radiography is not useful in the evaluation of the cruciate and collateral ligaments, the menisci, and the hyaline cartilage of the knee and may fail to show an insufficiency or stress fracture. To evaluate these structures and associated soft tissues, MRI is preferable.

COMPUTED TOMOGRAPHY IN ACUTE KNEE PAIN

CURRENT USES OF MRI TO EVALUATE ACUTE KNEE PAIN

As mentioned above, MRI is useful in evaluating suspected meniscal and ligamentous injuries.

Figure 3 shows how T2-weighted MRI was used to evaluate for suspected meniscal injury in our 47-year-old female patient with left knee pain after a motor vehicle accident.

Still a matter of debate

MRI’s role in the diagnosis of knee pain is still a contentious issue.

Advantages of MRI are that it is noninvasive, it does not use ionizing radiation, it gives multiplanar images, and it provides images of soft-tissue structures, which other imaging methods cannot.¹² It is a well-proven and widely accepted test. Its sensitivity for detecting meniscal and cruciate ligament injury ranges from 75% to 88%,¹ and it can help in the evaluation of other injuries for which radiography is not useful, including synovitis, bone bruise, stress or insufficiency fracture, osteochondral defects, and osteonecrosis.

In addition, several studies show that using MRI to establish the diagnosis in acute knee pain can mean that 22% to 42% fewer arthroscopic procedures need to be performed.^4–8 Authors of a prospective double-blind study⁸ recommended that MRI be used in patients with acute knee injury when the findings of the clinical history and examination by orthopedic surgeons prove equivocal.⁸ MRI evaluation is especially desirable for young, active patients who wish to resume activity as soon as possible.

A routine MRI examination consists of T1- and T2-weighted images in three planes, although the number of sequences and planes varies from hospital to hospital. The use of gadolinium contrast is indicated only when osteomyelitis, septic arthritis, or a mass is suspected.

Disadvantages of MRI include its cost: Medicare reimbursement for knee MRI is around $400, compared with $200 for knee CT and $50 for knee radiography with four views. Also, while studies have shown MRI to have a high sensitivity and specificity in the diagnosis of acute knee injury, some have reported a high false-positive rate for the detection of meniscal tear.¹³,¹⁴ MRI has also been shown to have a lower sensitivity than arthroscopy for lesions of the articular cartilage.¹³ Furthermore, MRI has been shown to reveal cartilage lesions, osteophytes, and meniscal abnormalities in asymptomatic study volunteers with no history of pain, trauma or knee disease.¹⁴ Therefore, findings on MRI must closely correlate with findings on the history and physical examination.

Additional indications for knee MRI

Cartilage can be assessed on routine MRI sequences of the knee. Since closed MRI systems have more powerful magnets than open systems, closed MRI systems provide greater anatomic detail.

MRI can identify other lesions, such as spontaneous osteonecrosis of the knee, usually seen in elderly women who may present with sudden knee pain. In such patients, MRI findings of focal replacement of the bone marrow and surrounding edema are specific for osteonecrosis.

Opinions vary as to whether bone marrow edema is always associated with pain. Sequential MRI studies have shown persistence of bone marrow edema for 2 years in patients with degenerative arthritis whose symptoms have waned. Bone marrow edema may be associated with pain but may be absent or inconsequential in the presence of pain.

Because fluid-sensitive T2-weighted MRI is exquisitely sensitive for mobile water protons (ie, in bone marrow edema), it is important that a cause for the edema-like signal be sought on the MRI scan, since this finding is nonspecific and may be associated with articular disease, trauma, osteonecrosis, infection, or bone tumors. Additionally, clinicians need to be aware that the findings on MRI depend on the quality of the study, and are influenced by technical factors such as magnet strength, imaging planes, and use of surface coils.

MRI should be used in patients in whom surgical treatment, ie, arthroscopy, is being considered. As discussed above, several studies have shown that a significant number of unnecessary arthroscopies may be prevented when preceded by an MRI examination.

Figure 5 shows the use of MRI in the evaluation of a 45-year-old man with left knee pain after a motorcycle accident.

ULTRASONOGRAPHY HAS ONLY A LIMITED ROLE

Ultrasonography does not play a major role in the evaluation of acute knee pain in the United States, in part because the accuracy of the results depend much on the technical skills and experience of the operator.

Ultrasonography can be useful in evaluating for rupture of the quadriceps and patellar tendon, or to assess a repaired tendon after surgery,¹⁵ and it is a quick and reliable way to determine the presence of joint effusion and popliteal cyst. It is also used to guide needle placement for joint aspiration and injection.

Radiography plays a key role in the initial evaluation of acute knee pain in adults. Yet conflicting studies and the absence of clear guidelines may leave the primary care physician uncertain as to which imaging test to order—ie, whether radiography is sufficient, and when computed tomography (CT) or magnetic resonance imaging (MRI) is needed. This article reviews the indications for radiologic examination of the knee and discusses indications for cross-sectional imaging studies. Imaging in oncology patients is not discussed here.

ACUTE KNEE PAIN: A TYPICAL SCENARIO

A 47-year-old woman presents to the emergency department with left knee pain after a motor vehicle accident that occurred the day before. The car she was driving hit a tree, and she hit her knee on the dashboard. She was wearing a seatbelt at the time of the accident. She says she was unable to walk immediately after the accident because of knee pain.

The initial examination in the emergency room reveals swelling and pain throughout the range of motion. The anterior drawer test and the Lachman test are negative (see below).

The patient is discharged home with a knee immobilizer, pain medication, and crutches, with instructions for a follow-up visit in the orthopedics clinic.

Five days later, she returns to the emergency department complaining of continuing knee pain. She says the knee gives way when she puts weight on it. The physical findings are unchanged, and she is discharged home with a follow-up appointment with orthopedics in 3 days.

At the follow-up visit, she complains of persistent knee pain in the medial aspect of the knee joint. Physical examination is difficult because of pain and swelling, and it reveals mild joint effusion with no gross instability. She has pain on the medial side with valgus stress, but there appears to be a hard end point. There is no posterior sag, and the Lachman test is negative.

Based on the physical examination and the patient’s complaints, she receives a diagnosis of medial collateral ligament strain and injury. She is given a hinged brace and is instructed to undergo a physical rehabilitation program.

Three weeks after the initial evaluation, she returns to the orthopedics clinic with continuing knee problems. Mild knee effusion persists, but she has less pain and swelling, allowing a more complete examination. The examination reveals less limitation of range of motion and a hint of positivity on the Lachman test. The knee is diffusely tender, and the pain seems out of proportion with the maneuvers used during the examination. She requests more pain medication. You suspect internal derangement of the knee. Which imaging test should you order to further evaluate this patient?

A SYSTEMATIC AND COST-EFFECTIVE APPROACH IS NEEDED

The case presented above represents a typical scenario for the presentation of acute knee pain and illustrates the diagnostic challenges.

Knee pain is a common reason for emergency room visits, and it accounts for approximately 1.9 million visits to primary care clinics annually.¹ In the emergency department, most patients undergo plain radiography to assess for fracture, yet approximately 92% of radiographic studies do not show a fracture.² Clearly, the evaluation of knee pain requires a systematic, accurate, and cost-effective approach.

Key elements of the physical examination

In acute knee pain, accurate diagnosis begins with a detailed history and physical examination.

The anterior drawer test is done to evaluate the anterior cruciate ligament. With the relaxed knee flexed to approximately 80° and the foot stabilized in a neutral position, the examiner grasps the proximal tibia in a firm yet gentle grip, and then applies anterior force, noting the degree of anterior displacement compared with the other knee.

The Lachman test, a variation of the anterior drawer test, is more definitive for the anterior cruciate ligament and is carried out with the knee in 15° of flexion and external rotation, in order to relax the iliotibial band. The upper hand grasps the distal thigh, and the lower hand, with the thumb on the tibial tubercle, pulls the tibia forward. The degree of anterior motion in millimeters is noted and compared with that on the other side, and the end point is graded as “soft” or “hard.” An end point is considered hard when a ligament abruptly halts the motion of the bone being tested against the stabilized bone. An end point is considered soft when the ligament is disrupted and the restraints are the more elastic secondary stabilizers.

Debate continues

Some authors contend that in skilled hands a thorough history, physical examination, and radiographic examination are sufficient to diagnose trauma-related intra-articular knee disorders.³ Others contend that MRI plays a key role in the initial evaluation. A number of studies^4–8 have shown that using MRI in the initial evaluation not only identifies key lesions, but also may eliminate the need for an invasive diagnostic procedure (ie, arthroscopy).

For example, MRI can reveal fracture, stress fracture, insufficiency fracture, and transient patellar dislocation—conditions that may satisfactorily explain knee symptoms.

PLAIN RADIOGRAPHY STILL THE FIRST STEP IN KNEE EVALUATION

Radiography is the first step in the evaluation of knee pain. It is quick and inexpensive and can yield many diagnostic clues. It can readily reveal fractures, osteochondral defects, bony lesions, joint effusions, joint space narrowing, and bone misalignment.

In patients with knee trauma, supine anteroposterior and cross-table lateral radiographic images are generally obtained. In patients whose knee pain is not due to trauma, standing projections are done, as well as dedicated projection of the patellofemoral articulation. A standing series is most helpful for evaluating joint space and alignment.

Applying the Ottawa rules

When a patient presents to the emergency room with acute knee pain, the immediate concern is whether he or she has a fracture. The Ottawa knee rules⁹ for when to order radiography in adults with knee pain are highly sensitive for detecting a clinically important fracture. If any one of the five Ottawa criteria applies—ie, the patient is age 55 or older, has tenderness at the head of the fibula, has patellar tenderness, is unable to flex the knee to 90°, or is unable to bear weight—then radiography is indicated.

While studies have validated the ability of the Ottawa rules to detect important fractures in acute knee injury,²,¹⁰ fracture is the cause of only a small percentage of knee complaints in the primary care setting. More common causes include osteoarthritis, meniscal injury, ligamental injury, and crystal arthropathy, and these account for approximately half of all diagnoses. Sprain and strain account for most of the rest of knee injuries.¹

Acute exacerbations of osteoarthritis

Osteoarthritis is a chronic problem, yet it is not unusual for a patient to present to the primary care physician with an acute exacerbation of joint pain. The clinical hallmarks include age over 50, stiffness lasting less than 30 minutes, bony enlargement and tenderness, and crepitus. The radiographic hallmarks, according to the Kellgren-Lawrence grading scale, are joint space narrowing, osteophytes, subchondral cysts, and sclerosis. These radiographic findings correlate well with clinical findings in these patients.¹¹

Situations in which radiography is less helpful

In some cases the radiographic findings may not explain the patient’s clinical signs and symptoms. For example, in suspected crystalline and septic arthritis, the clinical presentation may include warmth, erythema, and effusion. Arthrocentesis would be indicated in such a patient. Indeed, in the case of suspected pseudogout, chondrocalcinosis may be radiographically evident. However, it is also present in many patients without symptoms or with osteoarthritis, so radiographic evidence does not provide a definite diagnosis.

While radiography may not always identify the cause of knee pain, it is useful in excluding serious problems such as fractures, advanced degenerative changes, and neoplasms, and it may help direct further management. Radiography is not useful in the evaluation of the cruciate and collateral ligaments, the menisci, and the hyaline cartilage of the knee and may fail to show an insufficiency or stress fracture. To evaluate these structures and associated soft tissues, MRI is preferable.

COMPUTED TOMOGRAPHY IN ACUTE KNEE PAIN

CURRENT USES OF MRI TO EVALUATE ACUTE KNEE PAIN

As mentioned above, MRI is useful in evaluating suspected meniscal and ligamentous injuries.

Figure 3 shows how T2-weighted MRI was used to evaluate for suspected meniscal injury in our 47-year-old female patient with left knee pain after a motor vehicle accident.

Still a matter of debate

MRI’s role in the diagnosis of knee pain is still a contentious issue.

Advantages of MRI are that it is noninvasive, it does not use ionizing radiation, it gives multiplanar images, and it provides images of soft-tissue structures, which other imaging methods cannot.¹² It is a well-proven and widely accepted test. Its sensitivity for detecting meniscal and cruciate ligament injury ranges from 75% to 88%,¹ and it can help in the evaluation of other injuries for which radiography is not useful, including synovitis, bone bruise, stress or insufficiency fracture, osteochondral defects, and osteonecrosis.

In addition, several studies show that using MRI to establish the diagnosis in acute knee pain can mean that 22% to 42% fewer arthroscopic procedures need to be performed.^4–8 Authors of a prospective double-blind study⁸ recommended that MRI be used in patients with acute knee injury when the findings of the clinical history and examination by orthopedic surgeons prove equivocal.⁸ MRI evaluation is especially desirable for young, active patients who wish to resume activity as soon as possible.

A routine MRI examination consists of T1- and T2-weighted images in three planes, although the number of sequences and planes varies from hospital to hospital. The use of gadolinium contrast is indicated only when osteomyelitis, septic arthritis, or a mass is suspected.

Disadvantages of MRI include its cost: Medicare reimbursement for knee MRI is around $400, compared with $200 for knee CT and $50 for knee radiography with four views. Also, while studies have shown MRI to have a high sensitivity and specificity in the diagnosis of acute knee injury, some have reported a high false-positive rate for the detection of meniscal tear.¹³,¹⁴ MRI has also been shown to have a lower sensitivity than arthroscopy for lesions of the articular cartilage.¹³ Furthermore, MRI has been shown to reveal cartilage lesions, osteophytes, and meniscal abnormalities in asymptomatic study volunteers with no history of pain, trauma or knee disease.¹⁴ Therefore, findings on MRI must closely correlate with findings on the history and physical examination.

Additional indications for knee MRI

Cartilage can be assessed on routine MRI sequences of the knee. Since closed MRI systems have more powerful magnets than open systems, closed MRI systems provide greater anatomic detail.

MRI can identify other lesions, such as spontaneous osteonecrosis of the knee, usually seen in elderly women who may present with sudden knee pain. In such patients, MRI findings of focal replacement of the bone marrow and surrounding edema are specific for osteonecrosis.

Opinions vary as to whether bone marrow edema is always associated with pain. Sequential MRI studies have shown persistence of bone marrow edema for 2 years in patients with degenerative arthritis whose symptoms have waned. Bone marrow edema may be associated with pain but may be absent or inconsequential in the presence of pain.

Because fluid-sensitive T2-weighted MRI is exquisitely sensitive for mobile water protons (ie, in bone marrow edema), it is important that a cause for the edema-like signal be sought on the MRI scan, since this finding is nonspecific and may be associated with articular disease, trauma, osteonecrosis, infection, or bone tumors. Additionally, clinicians need to be aware that the findings on MRI depend on the quality of the study, and are influenced by technical factors such as magnet strength, imaging planes, and use of surface coils.

MRI should be used in patients in whom surgical treatment, ie, arthroscopy, is being considered. As discussed above, several studies have shown that a significant number of unnecessary arthroscopies may be prevented when preceded by an MRI examination.

Figure 5 shows the use of MRI in the evaluation of a 45-year-old man with left knee pain after a motorcycle accident.

ULTRASONOGRAPHY HAS ONLY A LIMITED ROLE

Ultrasonography does not play a major role in the evaluation of acute knee pain in the United States, in part because the accuracy of the results depend much on the technical skills and experience of the operator.

Ultrasonography can be useful in evaluating for rupture of the quadriceps and patellar tendon, or to assess a repaired tendon after surgery,¹⁵ and it is a quick and reliable way to determine the presence of joint effusion and popliteal cyst. It is also used to guide needle placement for joint aspiration and injection.