Abstract

Background A physician’s recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic.

Methods We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a “patient,” simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the physician-patient encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language.

Results Study physicians addressed a mean of 6.7 (standard deviation=1.8) of 13 key informational points. Most physicians (≥80%) discussed the benefits of colorectal cancer screening, the recognition of colonoscopy as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening (gain-framed messages), and many (67%) also used messages that focused on the risk of not screening (loss-framed messages). Numeracy information generally was expressed simply, but half of the physicians used statistical terms. Half used colloquial terms to describe the prep and procedure.

Conclusion Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study—perhaps with supplementary educational sources—will help ensure that patients are adequately prepared for colonoscopy.

Colorectal cancer screening has the potential to reduce deaths from colorectal cancer by at least one third.¹ Yet only half of eligible patients in the US who are age 50 or older have undergone screening.² Patients often say they haven’t been screened because their physician didn’t recommend it.^3-5

A physician’s recommendation is strongly predictive of whether a patient actually undergoes colorectal cancer screening, even after adjusting for multiple confounders.^6-9 Yet several studies have found that, even after the physician has recommended or ordered an endoscopic study of the colon, many patients do not follow through.^10-12 Successful completion of screening colonoscopy requires, in part, that a patient understand the need for the procedure and receive sufficient instruction about it. Thus, failure to undergo this test may reflect patient concerns or misunderstandings due to inadequate communication.^13,14

In many settings, the primary care physician bears the responsibility for telling the patient about screening colonoscopy because the endoscopist meets the patient only at the time of the procedure. Supplementary educational programs can also play a role. Unfortunately, though, while these materials appear to reduce patient anxiety and increase adherence to screening recommendations,^15-17 they are infrequently used.

Looking at physician communication with an eye toward improvement

Our goal in conducting this study was to evaluate the way in which physicians discuss the need for screening colonoscopy with their patients. Using a simulated patient scenario, we wanted to examine 4 dimensions of each discussion: completeness; type of messaging; type of numeracy information (ie, numerical and mathematical data); and use of colloquial vs technical language.

• Completeness reflected the number of key informational points addressed.
• Type of messaging focused on the use of loss- or gain-framed messages, both of which have been linked to increased patient intention to adopt a cancer prevention behavior or test.^18-20 Gain-framed counseling emphasizes the positive aspects of screening; loss-framed, the risks of not screening.
• Type of numeracy information. Because poor numeracy skills are thought to impair the accuracy of patients’ perceptions of cancer risk,²¹ we categorized the type of numeracy information provided by physicians following an approach developed by Ahlers-Schmidt and colleagues.²²
• Colloquial vs technical language. Because colonoscopy involves sensitive topics such as the bowels and feces, and because language choices may affect acceptance of care,²³ we evaluated physicians’ use of terminology when describing the procedure.

We felt that by looking at these dimensions, we could help physicians to refine screening colonoscopy messages so that conversations with patients could be more clear, complete, and balanced.

 

Methods

13 key points regarding screening colonoscopy

We reviewed published literature and Internet sources to develop a preliminary list of topics a primary care physician could address when discussing colorectal cancer screening, especially screening colonoscopy. We used NLM Gateway and Medline databases and the following search terms: colonoscopy, patient education, patient instructions, guidelines, physician, colon cancer, counseling, and knowledge. A medical librarian directed the search. Despite having expert assistance, we did not find any publications that offered a peer-reviewed, validated list of topics to guide physicians’ discussions about screening colonoscopy.

We then conducted an Internet search using the terms colon cancer, colon cancer screening, colonoscopy, and colon cancer patient education. We categorized data from identified sites such as the American Gastroenterological Association, Up-to-Date, the American Cancer Society, and the National Library of Medicine, among others, into 13 common topics (TABLE 1). Three points addressed general information about colorectal cancer, and the rest dealt with colonoscopy specifically. A panel of 2 gastroenterologists and 3 internists from the same institution independently judged each item on the list for importance, relevance, and feasibility for discussion. Except for one panelist, all endorsed the need to address the 13 items.

TABLE 1
Percentage of physicians who covered key colorectal cancer screening points

TOPIC	INFORMATIONAL POINT	PHYSICIANS ADDRESSING TOPIC (N=30), %
General colorectal prevention
1. Standard preventive health care procedure	Recommended* as a standard screening test for those age 50 and older	83
2. Value of screening	Can prevent cancer as well as detect cancer at a treatable stage	83
3. Risk of colorectal cancer	Prevalence or incidence either nationally or regionally (family history)†	43
Specifics about colonoscopy
4. Anesthesia	Sedation to reduce discomfort; risk information discussed or to be reviewed by anesthetist	87
5. Gastrointestinal prep	Use of laxative, usual types used, and what patient can expect	77
6. Abnormalities detected by colonoscopy	Finds growths (polyps) or cancer	76
7. Description of procedure	Camera at the end of a flexible tube views the entire colon and tiny tweezers at the end sample or remove growths	70
8. Follow-up after a negative test	Experts recommend screening after a negative test every 10 years	67
9. Patient experience or knowledge‡	Any personal or family/friend experience with colonoscopy or knowledge about the test	64
10. Transportation	Another person must accompany the patient after procedure	53
11. Insurance/scheduling	Insurance coverage, who arranges for the procedure, where test is performed	13
12. Diet	Diet the day before and day of procedure, importance of hydration	10
13. Risk of colonoscopy	Risk of bowel perforation or other complication	10
14. Medications	Changes in medications for the procedure	3
*Recommendation by expert panels need not be specified. Physicians often just say, “We recommend.”
†Family history not necessary in this study because the patient was said to be at average risk for colorectal cancer.
‡Point was not identified originally by the review and excluded from analysis.

Physician sample

Of 135 providers practicing in 2 primary care and 1 geriatrics practice affiliated with the same urban academic medical center, we invited 30 physicians to participate. This sample was chosen to adequately represent female and minority physicians as well as physicians at different levels of training (TABLE 2). The physicians were invited to participate either by e-mail (N=19) or in person (N=11), and all invitees consented. Interviews were conducted alone in the physician’s office or in a practice conference room, and they were audiotaped with the physician’s consent.

Interviews lasted fewer than 15 minutes and did not intrude on patient care time. Study physicians read a vignette of a fictitious 51-year-old African American woman who was an established patient in their practice, without a family history of colon cancer but with arthritis and hypertension. We asked each physician to inform the patient (simulated by the interviewer) about colorectal cancer screening and colonoscopy, as well as the logistics of getting this test. To standardize the interaction, interviewers predefined the patient’s responses to questions. For example, if the physician asked about prior knowledge of colonoscopy, the simulated patient replied that she had none. Study physicians were not prompted in any way and, though not given time restrictions, all were brief and to the point.

TABLE 2
Study physician characteristics

CHARACTERISTIC	PHYSICIANS WITH CHARACTERISTIC (N=30), %	INFORMATIONAL POINTS ADDRESSED,* MEAN (SD)
Total	100	6.73 (1.84)
Gender
Female	66	6.70 (1.89)
Male	34	6.80 (1.81)
Race
White	80	6.84 (1.80)
Non-white	20	6.20 (2.17)
Level of training
Attending	63	6.84 (1.98)
Trainee	37	6.54 (1.63)
Specialty
General Internal Medicine	90	6.89 (1.83)
Geriatrics	10	5.33 (1.53)
* All comparisons P >.05

Analysis

Interview transcripts were anonymous, identified only by a study number. The 2 study investigators coded transcribed interviews independently as to whether physicians addressed the 13 informational points. Inter-rater concordance in coding was 90%. We also independently evaluated the interviews according to the use of gain- or loss-framed messages (eg, detecting colon polyps early before cancer develops vs colorectal cancer being the second most common cause of cancer death). We independently classified types of numeracy information provided into 15 categories.²² We also independently examined audiotaped transcripts for examples of colloquial terms/slang or technical language. Because we are unaware of a validated approach to characterizing a physician’s language in this manner, we asked a layperson for assistance in identifying colloquial/slang terms.

 

To determine whether there were predictors of a physician addressing more of the informational points than his or her peers, we examined bivariate associations of the following demographic and professional data: gender, race (white vs non-white), academic advancement (attending vs trainee), and specialty (general internist vs geriatrician).

We analyzed data using the Wilcoxon rank-sum test because the data were not normally distributed. We used SAS Statistical Software (SAS Institute, Cary, NC). The University of Pennsylvania Institutional Review Board approved the study. The project was supported by a grant from the Bach Fund of the Presbyterian Medical Center, University of Pennsylvania.

Results

How did the physicians talk to their patient?

The 30 study physicians were primarily women, one fifth were from under-represented minorities, and one third were either residents or fellows (TABLE 2). Of 13 key informational points endorsed by our physician panel (TABLE 1), the physician-subjects addressed a mean of 6.7 points (range, 3–10). Nearly all physician-subjects discussed the value of colorectal cancer screening, colonoscopy as a standard colorectal screening procedure, and sedation during the procedure. However, fewer than 20% addressed the following topics: insurance/scheduling, dietary changes, medication modification, and risks of colonoscopy. In this small sample, the number of topics mentioned did not differ significantly by physician characteristic (TABLE 2).

Two thirds of the physicians asked the simulated patient about her prior knowledge or experience with colonoscopy. Although this question was not among the original 13 informational points, it helped to guide the discussion by identifying specific preconceptions or prior knowledge of this test. Therefore, this post hoc 14th informational point was added to our list but not considered in our analyses.

Gain-framed messages used more than loss-framed messages

Nearly all physicians used gain-framed messages, and more than half also used loss-framed messages (TABLE 3). Only 1 physician offered only a loss-framed message. Overall, study physicians mentioned less than 2 gain- or loss-framed messages.

• The most common types of gain-framed messages were detecting cancer early, preventing cancer by taking out polyps, and screening at only a 10-year interval if the test result is negative.
• The most common loss-framed messages noted that colorectal cancer was the second most common cause of cancer death and that risk is increased with a family history of this cancer.

TABLE 3
Gain- and loss-framed messages and types of numeracy information used by study physicians

TYPE OF MESSAGE OR NUMERACY	PHYSICIANS N (%)	OCCURRENCES IN INTERVIEWS, Total N (MEAN AMONG USERS, RANGE)
Message framing
Gain-framed	29 (96)	56 (1.9, 1–5)
Loss-framed	20 (67)	31 (1.6, 1–3)
Numeracy
Descriptive terms	19 (63)	36 (1.9, 1–3)
Statistical terms	15 (50)	30 (2.0, 1–5)
Temporal terms	9 (30)	11 (1.2, 1–2)
Proportions	4 (13)	5 (1.3, 1–2)
Fractions	3 (10)	3 (1.0, 1–1)

Physicians avoided using numbers

Of the 15 types of numeracy information described by Ahlers-Schmit et al, our physicians used only 5. Nineteen physicians (63%) used descriptive terms such as “likely” or “increased,” and 15 (50%) used statistical concepts such as risk and second-most-common cause. Physicians avoided using numbers; 9 (30%) used temporal terms such as “early”; 4 (13%) cited a proportion; and only 3 (10%) used a fraction.

Colloquial language, or was it crude?

While reading the transcripts, we noted that some physicians used colloquial terms that could be regarded as crude. Other terms were probably too technical without an explanation. Some information was simply incorrect. We offer selected quotes to illustrate various types of language used.

About the prep:

• “Getting a colonoscopy is not the most fun experience…you have really bad diarrhea and you just empty out your guts.”
• “It’s basically Liquid Plumber for your bowels.”
• “Bowel prep…is kind of voluminous and associated with kind of massive bowel movements.”
• “Everybody hates the prep and you may be one of those and that’s just that.”
• “Generally you have to be up all night, sometimes, cleaning your bowels out.”

About the procedure:

• “It’s not the most comfortable screening exam in the world.”
• “It’s a test where they stick a lighted tube up your back-side.”
• “The stomach doctors put a camera up your bottom and look at the walls of your colon.”
• “They can go in with a microscope and look around and look at the colon itself.”
• “It’s a painless test.”

Word polyp is used, but not defined

Physicians often employed technical language when describing the pathology detected by colonoscopy. “Polyp” was mentioned by 20 physicians (67%) but rarely defined; “biopsy” by 5 (17%), and “lesion” by 6 (20%). Other technical terms were precancerous, symptomatic, and incapacitated.

 

Discussion

An informed patient is a willing patient

Our study physicians addressed only half of the 13 informational points, likely reflecting the time constraints of a typical office visit. Primary care physicians appear to expect that either the colonoscopist or other sources of information would fill in the gaps. As reported in several studies, unanswered questions can discourage patients from keeping their scheduled colonoscopy appointment.^10,11 In one report of African-American church members, those with adequate knowledge about colorectal cancer screening were more likely to complete screening.²⁴

Wolf and Becker suggested that discussions about cancer screening address 4 broad topics: the probability of developing the cancer, the operating characteristics of the screening test(s), the likelihood that screening will benefit the patient, and potential burdens of the test.²⁵ Instead of a balanced and lengthy discussion, our study physicians generally emphasized the positives such as the value of avoiding colon cancer, the standard nature of this test, and the benefit of being sedated for the procedure. Thus, gain-framed messages about colorectal cancer were the norm for our study physicians.

Half of the physicians also offered loss-framed messages emphasizing the need to avoid the consequences of colorectal cancer and the increased threat associated with a family history of this malignancy. Research in mammography screening suggests that loss-framed messaging may be a more powerful motivator than gain-framed messaging,²⁶ but it is not clear if this observation can be generalized to colorectal cancer screening.

Walking a fine line with the particulars of risk

Our study physicians rarely provided data on the probability of developing colorectal cancer. Physicians may avoid this topic because many patients have difficulty understanding information about the risk of colorectal cancer.¹¹ In support of this approach, Lipkus and colleagues reported that various ways of informing patients about colorectal cancer risk did not affect their intention to be screened.²⁷ Of concern, most of our physicians did not address the common misconception that colorectal cancer screening is unnecessary in the absence of symptoms.²⁸

Overall, the level of numeracy information provided by study physicians required minimal patient understanding of mathematical and statistical concepts. Most information was descriptive, such as colonoscopy being “more thorough” than other tests. Though statistical concepts such as “risk” were often mentioned, few physicians offered probabilities or incidence data. Experts recommend providing such data,²⁵ but Web sites have been criticized for offering excessive numerical cancer risk data.²² Therefore, physicians must walk a fine line between providing adequate information and offering data that require a high level of health numeracy for understanding.

6 key points physicians often overlook

Most physicians failed to mention dietary and medication changes, scheduling/insurance coverage issues, and risk of complications from colonoscopy. Nearly 60% failed to discuss the patient’s risk of colorectal cancer. Almost half did not mention the need for a companion to accompany the patient after the test. Scheduling challenges, in particular, are known to interfere with completing colonoscopy.¹¹

Many neglect to describe the procedure

Thirty percent of physicians failed to describe the procedure itself, so it is not surprising that patients complain they have a poor understanding of test logistics.^11,29,30 Denberg and colleagues have reported that mailing an informational brochure about colonoscopy can increase the number who keep their appointment.³¹

How language choices may affect understanding

Other researchers have identified additional patient barriers to colonoscopy, including fear of pain, concern for modesty, and desire to avoid the bowel prep.^11,32 These concerns may be mitigated or heightened by the physician’s language. In our review of transcripts, physicians often used slang or colloquial language to describe the procedure, probably in an attempt to convey information in a familiar way. This language may be viewed as crude and potentially discouraging, but further research is needed to evaluate patient receptiveness to different ways of speaking about sensitive topics.

Additionally, physicians commonly used technical terms such as “polyp” and “biopsy” without explaining them. Technical language may increase racial disparities in adhering to scheduled colonoscopy. In a family medicine clinic, patients from minority groups had particular difficulty understanding medical terms and procedure names.²⁸ Because little time is available for counseling about cancer screening tests, and because patients retain only a limited amount of information about procedures,³³ supplementary informational sources are warranted.^15-17,31 Options include brochures, telephone calls, letters, e-mails, Web site data, and videotapes, but it is unclear which sources optimally improve patient adherence to screening colonoscopy.³⁴

 

Study limitations include simulated interaction

There were a number of limitations to this study. First, the investigators “simulated” the patient. Though study physicians were told to act as if they were speaking to a regular patient, they may still have unconsciously modified their usual approach to addressing this topic.

Second, we did not assess the effectiveness of these discussions in motivating actual patients to receive colonoscopy.

Other limitations included the following:

• We did not set a time period for these discussions, so they may have been even more limited in actual practice.
• We studied physicians from a single health care setting wherein colonoscopy appears to be the preferred approach to screen an average risk patient for colorectal cancer. In addition, in this health care system, this test is performed by a gastroenterologist, rather than a primary care physician.
• We did not determine whether patients regard our selected quotes as too colloquial or technical.
• This study did not address the important barrier of a physician forgetting to recommend colorectal cancer screening.³⁵

Further research, next steps

Our study supports the hypothesis that physicians differ widely—but are generally deficient—when informing patients about screening colonoscopy. They generally emphasize the positives of colonoscopy and use terms that are colloquial, avoiding statistical concepts that may be hard for patients to understand. Future studies need to address the effectiveness of these approaches to discussing screening colonoscopy.

Given the central role of the primary care physician in motivating patients to undergo screening colonoscopy in a limited time period, it appears that additional supports are needed to supplement physician discussion about this important preventive care procedure.

Correspondence
Barbara J. Turner MD, MSEd, University of Pennsylvania, 1123 Blockley Hall/6021, 423 Guardian Drive, Philadelphia, PA 19104; bturner@mail.med.upenn.edu

Abstract

Background A physician’s recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic.

Methods We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a “patient,” simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the physician-patient encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language.

Results Study physicians addressed a mean of 6.7 (standard deviation=1.8) of 13 key informational points. Most physicians (≥80%) discussed the benefits of colorectal cancer screening, the recognition of colonoscopy as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening (gain-framed messages), and many (67%) also used messages that focused on the risk of not screening (loss-framed messages). Numeracy information generally was expressed simply, but half of the physicians used statistical terms. Half used colloquial terms to describe the prep and procedure.

Conclusion Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study—perhaps with supplementary educational sources—will help ensure that patients are adequately prepared for colonoscopy.

Colorectal cancer screening has the potential to reduce deaths from colorectal cancer by at least one third.¹ Yet only half of eligible patients in the US who are age 50 or older have undergone screening.² Patients often say they haven’t been screened because their physician didn’t recommend it.^3-5

A physician’s recommendation is strongly predictive of whether a patient actually undergoes colorectal cancer screening, even after adjusting for multiple confounders.^6-9 Yet several studies have found that, even after the physician has recommended or ordered an endoscopic study of the colon, many patients do not follow through.^10-12 Successful completion of screening colonoscopy requires, in part, that a patient understand the need for the procedure and receive sufficient instruction about it. Thus, failure to undergo this test may reflect patient concerns or misunderstandings due to inadequate communication.^13,14

In many settings, the primary care physician bears the responsibility for telling the patient about screening colonoscopy because the endoscopist meets the patient only at the time of the procedure. Supplementary educational programs can also play a role. Unfortunately, though, while these materials appear to reduce patient anxiety and increase adherence to screening recommendations,^15-17 they are infrequently used.

Looking at physician communication with an eye toward improvement

Our goal in conducting this study was to evaluate the way in which physicians discuss the need for screening colonoscopy with their patients. Using a simulated patient scenario, we wanted to examine 4 dimensions of each discussion: completeness; type of messaging; type of numeracy information (ie, numerical and mathematical data); and use of colloquial vs technical language.

• Completeness reflected the number of key informational points addressed.
• Type of messaging focused on the use of loss- or gain-framed messages, both of which have been linked to increased patient intention to adopt a cancer prevention behavior or test.^18-20 Gain-framed counseling emphasizes the positive aspects of screening; loss-framed, the risks of not screening.
• Type of numeracy information. Because poor numeracy skills are thought to impair the accuracy of patients’ perceptions of cancer risk,²¹ we categorized the type of numeracy information provided by physicians following an approach developed by Ahlers-Schmidt and colleagues.²²
• Colloquial vs technical language. Because colonoscopy involves sensitive topics such as the bowels and feces, and because language choices may affect acceptance of care,²³ we evaluated physicians’ use of terminology when describing the procedure.

We felt that by looking at these dimensions, we could help physicians to refine screening colonoscopy messages so that conversations with patients could be more clear, complete, and balanced.

 

Methods

13 key points regarding screening colonoscopy

We reviewed published literature and Internet sources to develop a preliminary list of topics a primary care physician could address when discussing colorectal cancer screening, especially screening colonoscopy. We used NLM Gateway and Medline databases and the following search terms: colonoscopy, patient education, patient instructions, guidelines, physician, colon cancer, counseling, and knowledge. A medical librarian directed the search. Despite having expert assistance, we did not find any publications that offered a peer-reviewed, validated list of topics to guide physicians’ discussions about screening colonoscopy.

We then conducted an Internet search using the terms colon cancer, colon cancer screening, colonoscopy, and colon cancer patient education. We categorized data from identified sites such as the American Gastroenterological Association, Up-to-Date, the American Cancer Society, and the National Library of Medicine, among others, into 13 common topics (TABLE 1). Three points addressed general information about colorectal cancer, and the rest dealt with colonoscopy specifically. A panel of 2 gastroenterologists and 3 internists from the same institution independently judged each item on the list for importance, relevance, and feasibility for discussion. Except for one panelist, all endorsed the need to address the 13 items.

TABLE 1
Percentage of physicians who covered key colorectal cancer screening points

TOPIC	INFORMATIONAL POINT	PHYSICIANS ADDRESSING TOPIC (N=30), %
General colorectal prevention
1. Standard preventive health care procedure	Recommended* as a standard screening test for those age 50 and older	83
2. Value of screening	Can prevent cancer as well as detect cancer at a treatable stage	83
3. Risk of colorectal cancer	Prevalence or incidence either nationally or regionally (family history)†	43
Specifics about colonoscopy
4. Anesthesia	Sedation to reduce discomfort; risk information discussed or to be reviewed by anesthetist	87
5. Gastrointestinal prep	Use of laxative, usual types used, and what patient can expect	77
6. Abnormalities detected by colonoscopy	Finds growths (polyps) or cancer	76
7. Description of procedure	Camera at the end of a flexible tube views the entire colon and tiny tweezers at the end sample or remove growths	70
8. Follow-up after a negative test	Experts recommend screening after a negative test every 10 years	67
9. Patient experience or knowledge‡	Any personal or family/friend experience with colonoscopy or knowledge about the test	64
10. Transportation	Another person must accompany the patient after procedure	53
11. Insurance/scheduling	Insurance coverage, who arranges for the procedure, where test is performed	13
12. Diet	Diet the day before and day of procedure, importance of hydration	10
13. Risk of colonoscopy	Risk of bowel perforation or other complication	10
14. Medications	Changes in medications for the procedure	3
*Recommendation by expert panels need not be specified. Physicians often just say, “We recommend.”
†Family history not necessary in this study because the patient was said to be at average risk for colorectal cancer.
‡Point was not identified originally by the review and excluded from analysis.

Physician sample

Of 135 providers practicing in 2 primary care and 1 geriatrics practice affiliated with the same urban academic medical center, we invited 30 physicians to participate. This sample was chosen to adequately represent female and minority physicians as well as physicians at different levels of training (TABLE 2). The physicians were invited to participate either by e-mail (N=19) or in person (N=11), and all invitees consented. Interviews were conducted alone in the physician’s office or in a practice conference room, and they were audiotaped with the physician’s consent.

Interviews lasted fewer than 15 minutes and did not intrude on patient care time. Study physicians read a vignette of a fictitious 51-year-old African American woman who was an established patient in their practice, without a family history of colon cancer but with arthritis and hypertension. We asked each physician to inform the patient (simulated by the interviewer) about colorectal cancer screening and colonoscopy, as well as the logistics of getting this test. To standardize the interaction, interviewers predefined the patient’s responses to questions. For example, if the physician asked about prior knowledge of colonoscopy, the simulated patient replied that she had none. Study physicians were not prompted in any way and, though not given time restrictions, all were brief and to the point.

TABLE 2
Study physician characteristics

CHARACTERISTIC	PHYSICIANS WITH CHARACTERISTIC (N=30), %	INFORMATIONAL POINTS ADDRESSED,* MEAN (SD)
Total	100	6.73 (1.84)
Gender
Female	66	6.70 (1.89)
Male	34	6.80 (1.81)
Race
White	80	6.84 (1.80)
Non-white	20	6.20 (2.17)
Level of training
Attending	63	6.84 (1.98)
Trainee	37	6.54 (1.63)
Specialty
General Internal Medicine	90	6.89 (1.83)
Geriatrics	10	5.33 (1.53)
* All comparisons P >.05

Analysis

Interview transcripts were anonymous, identified only by a study number. The 2 study investigators coded transcribed interviews independently as to whether physicians addressed the 13 informational points. Inter-rater concordance in coding was 90%. We also independently evaluated the interviews according to the use of gain- or loss-framed messages (eg, detecting colon polyps early before cancer develops vs colorectal cancer being the second most common cause of cancer death). We independently classified types of numeracy information provided into 15 categories.²² We also independently examined audiotaped transcripts for examples of colloquial terms/slang or technical language. Because we are unaware of a validated approach to characterizing a physician’s language in this manner, we asked a layperson for assistance in identifying colloquial/slang terms.

 

To determine whether there were predictors of a physician addressing more of the informational points than his or her peers, we examined bivariate associations of the following demographic and professional data: gender, race (white vs non-white), academic advancement (attending vs trainee), and specialty (general internist vs geriatrician).

We analyzed data using the Wilcoxon rank-sum test because the data were not normally distributed. We used SAS Statistical Software (SAS Institute, Cary, NC). The University of Pennsylvania Institutional Review Board approved the study. The project was supported by a grant from the Bach Fund of the Presbyterian Medical Center, University of Pennsylvania.

Results

How did the physicians talk to their patient?

The 30 study physicians were primarily women, one fifth were from under-represented minorities, and one third were either residents or fellows (TABLE 2). Of 13 key informational points endorsed by our physician panel (TABLE 1), the physician-subjects addressed a mean of 6.7 points (range, 3–10). Nearly all physician-subjects discussed the value of colorectal cancer screening, colonoscopy as a standard colorectal screening procedure, and sedation during the procedure. However, fewer than 20% addressed the following topics: insurance/scheduling, dietary changes, medication modification, and risks of colonoscopy. In this small sample, the number of topics mentioned did not differ significantly by physician characteristic (TABLE 2).

Two thirds of the physicians asked the simulated patient about her prior knowledge or experience with colonoscopy. Although this question was not among the original 13 informational points, it helped to guide the discussion by identifying specific preconceptions or prior knowledge of this test. Therefore, this post hoc 14th informational point was added to our list but not considered in our analyses.

Gain-framed messages used more than loss-framed messages

Nearly all physicians used gain-framed messages, and more than half also used loss-framed messages (TABLE 3). Only 1 physician offered only a loss-framed message. Overall, study physicians mentioned less than 2 gain- or loss-framed messages.

• The most common types of gain-framed messages were detecting cancer early, preventing cancer by taking out polyps, and screening at only a 10-year interval if the test result is negative.
• The most common loss-framed messages noted that colorectal cancer was the second most common cause of cancer death and that risk is increased with a family history of this cancer.

TABLE 3
Gain- and loss-framed messages and types of numeracy information used by study physicians

TYPE OF MESSAGE OR NUMERACY	PHYSICIANS N (%)	OCCURRENCES IN INTERVIEWS, Total N (MEAN AMONG USERS, RANGE)
Message framing
Gain-framed	29 (96)	56 (1.9, 1–5)
Loss-framed	20 (67)	31 (1.6, 1–3)
Numeracy
Descriptive terms	19 (63)	36 (1.9, 1–3)
Statistical terms	15 (50)	30 (2.0, 1–5)
Temporal terms	9 (30)	11 (1.2, 1–2)
Proportions	4 (13)	5 (1.3, 1–2)
Fractions	3 (10)	3 (1.0, 1–1)

Physicians avoided using numbers

Of the 15 types of numeracy information described by Ahlers-Schmit et al, our physicians used only 5. Nineteen physicians (63%) used descriptive terms such as “likely” or “increased,” and 15 (50%) used statistical concepts such as risk and second-most-common cause. Physicians avoided using numbers; 9 (30%) used temporal terms such as “early”; 4 (13%) cited a proportion; and only 3 (10%) used a fraction.

Colloquial language, or was it crude?

While reading the transcripts, we noted that some physicians used colloquial terms that could be regarded as crude. Other terms were probably too technical without an explanation. Some information was simply incorrect. We offer selected quotes to illustrate various types of language used.

About the prep:

• “Getting a colonoscopy is not the most fun experience…you have really bad diarrhea and you just empty out your guts.”
• “It’s basically Liquid Plumber for your bowels.”
• “Bowel prep…is kind of voluminous and associated with kind of massive bowel movements.”
• “Everybody hates the prep and you may be one of those and that’s just that.”
• “Generally you have to be up all night, sometimes, cleaning your bowels out.”

About the procedure:

• “It’s not the most comfortable screening exam in the world.”
• “It’s a test where they stick a lighted tube up your back-side.”
• “The stomach doctors put a camera up your bottom and look at the walls of your colon.”
• “They can go in with a microscope and look around and look at the colon itself.”
• “It’s a painless test.”

Word polyp is used, but not defined

Physicians often employed technical language when describing the pathology detected by colonoscopy. “Polyp” was mentioned by 20 physicians (67%) but rarely defined; “biopsy” by 5 (17%), and “lesion” by 6 (20%). Other technical terms were precancerous, symptomatic, and incapacitated.

 

Discussion

An informed patient is a willing patient

Our study physicians addressed only half of the 13 informational points, likely reflecting the time constraints of a typical office visit. Primary care physicians appear to expect that either the colonoscopist or other sources of information would fill in the gaps. As reported in several studies, unanswered questions can discourage patients from keeping their scheduled colonoscopy appointment.^10,11 In one report of African-American church members, those with adequate knowledge about colorectal cancer screening were more likely to complete screening.²⁴

Wolf and Becker suggested that discussions about cancer screening address 4 broad topics: the probability of developing the cancer, the operating characteristics of the screening test(s), the likelihood that screening will benefit the patient, and potential burdens of the test.²⁵ Instead of a balanced and lengthy discussion, our study physicians generally emphasized the positives such as the value of avoiding colon cancer, the standard nature of this test, and the benefit of being sedated for the procedure. Thus, gain-framed messages about colorectal cancer were the norm for our study physicians.

Half of the physicians also offered loss-framed messages emphasizing the need to avoid the consequences of colorectal cancer and the increased threat associated with a family history of this malignancy. Research in mammography screening suggests that loss-framed messaging may be a more powerful motivator than gain-framed messaging,²⁶ but it is not clear if this observation can be generalized to colorectal cancer screening.

Walking a fine line with the particulars of risk

Our study physicians rarely provided data on the probability of developing colorectal cancer. Physicians may avoid this topic because many patients have difficulty understanding information about the risk of colorectal cancer.¹¹ In support of this approach, Lipkus and colleagues reported that various ways of informing patients about colorectal cancer risk did not affect their intention to be screened.²⁷ Of concern, most of our physicians did not address the common misconception that colorectal cancer screening is unnecessary in the absence of symptoms.²⁸

Overall, the level of numeracy information provided by study physicians required minimal patient understanding of mathematical and statistical concepts. Most information was descriptive, such as colonoscopy being “more thorough” than other tests. Though statistical concepts such as “risk” were often mentioned, few physicians offered probabilities or incidence data. Experts recommend providing such data,²⁵ but Web sites have been criticized for offering excessive numerical cancer risk data.²² Therefore, physicians must walk a fine line between providing adequate information and offering data that require a high level of health numeracy for understanding.

6 key points physicians often overlook

Most physicians failed to mention dietary and medication changes, scheduling/insurance coverage issues, and risk of complications from colonoscopy. Nearly 60% failed to discuss the patient’s risk of colorectal cancer. Almost half did not mention the need for a companion to accompany the patient after the test. Scheduling challenges, in particular, are known to interfere with completing colonoscopy.¹¹

Many neglect to describe the procedure

Thirty percent of physicians failed to describe the procedure itself, so it is not surprising that patients complain they have a poor understanding of test logistics.^11,29,30 Denberg and colleagues have reported that mailing an informational brochure about colonoscopy can increase the number who keep their appointment.³¹

How language choices may affect understanding

Other researchers have identified additional patient barriers to colonoscopy, including fear of pain, concern for modesty, and desire to avoid the bowel prep.^11,32 These concerns may be mitigated or heightened by the physician’s language. In our review of transcripts, physicians often used slang or colloquial language to describe the procedure, probably in an attempt to convey information in a familiar way. This language may be viewed as crude and potentially discouraging, but further research is needed to evaluate patient receptiveness to different ways of speaking about sensitive topics.

Additionally, physicians commonly used technical terms such as “polyp” and “biopsy” without explaining them. Technical language may increase racial disparities in adhering to scheduled colonoscopy. In a family medicine clinic, patients from minority groups had particular difficulty understanding medical terms and procedure names.²⁸ Because little time is available for counseling about cancer screening tests, and because patients retain only a limited amount of information about procedures,³³ supplementary informational sources are warranted.^15-17,31 Options include brochures, telephone calls, letters, e-mails, Web site data, and videotapes, but it is unclear which sources optimally improve patient adherence to screening colonoscopy.³⁴

 

Study limitations include simulated interaction

There were a number of limitations to this study. First, the investigators “simulated” the patient. Though study physicians were told to act as if they were speaking to a regular patient, they may still have unconsciously modified their usual approach to addressing this topic.

Second, we did not assess the effectiveness of these discussions in motivating actual patients to receive colonoscopy.

Other limitations included the following:

• We did not set a time period for these discussions, so they may have been even more limited in actual practice.
• We studied physicians from a single health care setting wherein colonoscopy appears to be the preferred approach to screen an average risk patient for colorectal cancer. In addition, in this health care system, this test is performed by a gastroenterologist, rather than a primary care physician.
• We did not determine whether patients regard our selected quotes as too colloquial or technical.
• This study did not address the important barrier of a physician forgetting to recommend colorectal cancer screening.³⁵

Further research, next steps

Our study supports the hypothesis that physicians differ widely—but are generally deficient—when informing patients about screening colonoscopy. They generally emphasize the positives of colonoscopy and use terms that are colloquial, avoiding statistical concepts that may be hard for patients to understand. Future studies need to address the effectiveness of these approaches to discussing screening colonoscopy.

Given the central role of the primary care physician in motivating patients to undergo screening colonoscopy in a limited time period, it appears that additional supports are needed to supplement physician discussion about this important preventive care procedure.

Correspondence
Barbara J. Turner MD, MSEd, University of Pennsylvania, 1123 Blockley Hall/6021, 423 Guardian Drive, Philadelphia, PA 19104; bturner@mail.med.upenn.edu

Abstract

Background A physician’s recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic.

Methods We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a “patient,” simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the physician-patient encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language.

Results Study physicians addressed a mean of 6.7 (standard deviation=1.8) of 13 key informational points. Most physicians (≥80%) discussed the benefits of colorectal cancer screening, the recognition of colonoscopy as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening (gain-framed messages), and many (67%) also used messages that focused on the risk of not screening (loss-framed messages). Numeracy information generally was expressed simply, but half of the physicians used statistical terms. Half used colloquial terms to describe the prep and procedure.

Conclusion Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study—perhaps with supplementary educational sources—will help ensure that patients are adequately prepared for colonoscopy.

Colorectal cancer screening has the potential to reduce deaths from colorectal cancer by at least one third.¹ Yet only half of eligible patients in the US who are age 50 or older have undergone screening.² Patients often say they haven’t been screened because their physician didn’t recommend it.^3-5

A physician’s recommendation is strongly predictive of whether a patient actually undergoes colorectal cancer screening, even after adjusting for multiple confounders.^6-9 Yet several studies have found that, even after the physician has recommended or ordered an endoscopic study of the colon, many patients do not follow through.^10-12 Successful completion of screening colonoscopy requires, in part, that a patient understand the need for the procedure and receive sufficient instruction about it. Thus, failure to undergo this test may reflect patient concerns or misunderstandings due to inadequate communication.^13,14

In many settings, the primary care physician bears the responsibility for telling the patient about screening colonoscopy because the endoscopist meets the patient only at the time of the procedure. Supplementary educational programs can also play a role. Unfortunately, though, while these materials appear to reduce patient anxiety and increase adherence to screening recommendations,^15-17 they are infrequently used.

Looking at physician communication with an eye toward improvement

Our goal in conducting this study was to evaluate the way in which physicians discuss the need for screening colonoscopy with their patients. Using a simulated patient scenario, we wanted to examine 4 dimensions of each discussion: completeness; type of messaging; type of numeracy information (ie, numerical and mathematical data); and use of colloquial vs technical language.

• Completeness reflected the number of key informational points addressed.
• Type of messaging focused on the use of loss- or gain-framed messages, both of which have been linked to increased patient intention to adopt a cancer prevention behavior or test.^18-20 Gain-framed counseling emphasizes the positive aspects of screening; loss-framed, the risks of not screening.
• Type of numeracy information. Because poor numeracy skills are thought to impair the accuracy of patients’ perceptions of cancer risk,²¹ we categorized the type of numeracy information provided by physicians following an approach developed by Ahlers-Schmidt and colleagues.²²
• Colloquial vs technical language. Because colonoscopy involves sensitive topics such as the bowels and feces, and because language choices may affect acceptance of care,²³ we evaluated physicians’ use of terminology when describing the procedure.

We felt that by looking at these dimensions, we could help physicians to refine screening colonoscopy messages so that conversations with patients could be more clear, complete, and balanced.

 

Methods

13 key points regarding screening colonoscopy

We reviewed published literature and Internet sources to develop a preliminary list of topics a primary care physician could address when discussing colorectal cancer screening, especially screening colonoscopy. We used NLM Gateway and Medline databases and the following search terms: colonoscopy, patient education, patient instructions, guidelines, physician, colon cancer, counseling, and knowledge. A medical librarian directed the search. Despite having expert assistance, we did not find any publications that offered a peer-reviewed, validated list of topics to guide physicians’ discussions about screening colonoscopy.

We then conducted an Internet search using the terms colon cancer, colon cancer screening, colonoscopy, and colon cancer patient education. We categorized data from identified sites such as the American Gastroenterological Association, Up-to-Date, the American Cancer Society, and the National Library of Medicine, among others, into 13 common topics (TABLE 1). Three points addressed general information about colorectal cancer, and the rest dealt with colonoscopy specifically. A panel of 2 gastroenterologists and 3 internists from the same institution independently judged each item on the list for importance, relevance, and feasibility for discussion. Except for one panelist, all endorsed the need to address the 13 items.

TABLE 1
Percentage of physicians who covered key colorectal cancer screening points

TOPIC	INFORMATIONAL POINT	PHYSICIANS ADDRESSING TOPIC (N=30), %
General colorectal prevention
1. Standard preventive health care procedure	Recommended* as a standard screening test for those age 50 and older	83
2. Value of screening	Can prevent cancer as well as detect cancer at a treatable stage	83
3. Risk of colorectal cancer	Prevalence or incidence either nationally or regionally (family history)†	43
Specifics about colonoscopy
4. Anesthesia	Sedation to reduce discomfort; risk information discussed or to be reviewed by anesthetist	87
5. Gastrointestinal prep	Use of laxative, usual types used, and what patient can expect	77
6. Abnormalities detected by colonoscopy	Finds growths (polyps) or cancer	76
7. Description of procedure	Camera at the end of a flexible tube views the entire colon and tiny tweezers at the end sample or remove growths	70
8. Follow-up after a negative test	Experts recommend screening after a negative test every 10 years	67
9. Patient experience or knowledge‡	Any personal or family/friend experience with colonoscopy or knowledge about the test	64
10. Transportation	Another person must accompany the patient after procedure	53
11. Insurance/scheduling	Insurance coverage, who arranges for the procedure, where test is performed	13
12. Diet	Diet the day before and day of procedure, importance of hydration	10
13. Risk of colonoscopy	Risk of bowel perforation or other complication	10
14. Medications	Changes in medications for the procedure	3
*Recommendation by expert panels need not be specified. Physicians often just say, “We recommend.”
†Family history not necessary in this study because the patient was said to be at average risk for colorectal cancer.
‡Point was not identified originally by the review and excluded from analysis.

Physician sample

Of 135 providers practicing in 2 primary care and 1 geriatrics practice affiliated with the same urban academic medical center, we invited 30 physicians to participate. This sample was chosen to adequately represent female and minority physicians as well as physicians at different levels of training (TABLE 2). The physicians were invited to participate either by e-mail (N=19) or in person (N=11), and all invitees consented. Interviews were conducted alone in the physician’s office or in a practice conference room, and they were audiotaped with the physician’s consent.

Interviews lasted fewer than 15 minutes and did not intrude on patient care time. Study physicians read a vignette of a fictitious 51-year-old African American woman who was an established patient in their practice, without a family history of colon cancer but with arthritis and hypertension. We asked each physician to inform the patient (simulated by the interviewer) about colorectal cancer screening and colonoscopy, as well as the logistics of getting this test. To standardize the interaction, interviewers predefined the patient’s responses to questions. For example, if the physician asked about prior knowledge of colonoscopy, the simulated patient replied that she had none. Study physicians were not prompted in any way and, though not given time restrictions, all were brief and to the point.

TABLE 2
Study physician characteristics

CHARACTERISTIC	PHYSICIANS WITH CHARACTERISTIC (N=30), %	INFORMATIONAL POINTS ADDRESSED,* MEAN (SD)
Total	100	6.73 (1.84)
Gender
Female	66	6.70 (1.89)
Male	34	6.80 (1.81)
Race
White	80	6.84 (1.80)
Non-white	20	6.20 (2.17)
Level of training
Attending	63	6.84 (1.98)
Trainee	37	6.54 (1.63)
Specialty
General Internal Medicine	90	6.89 (1.83)
Geriatrics	10	5.33 (1.53)
* All comparisons P >.05

Analysis

Interview transcripts were anonymous, identified only by a study number. The 2 study investigators coded transcribed interviews independently as to whether physicians addressed the 13 informational points. Inter-rater concordance in coding was 90%. We also independently evaluated the interviews according to the use of gain- or loss-framed messages (eg, detecting colon polyps early before cancer develops vs colorectal cancer being the second most common cause of cancer death). We independently classified types of numeracy information provided into 15 categories.²² We also independently examined audiotaped transcripts for examples of colloquial terms/slang or technical language. Because we are unaware of a validated approach to characterizing a physician’s language in this manner, we asked a layperson for assistance in identifying colloquial/slang terms.

 

To determine whether there were predictors of a physician addressing more of the informational points than his or her peers, we examined bivariate associations of the following demographic and professional data: gender, race (white vs non-white), academic advancement (attending vs trainee), and specialty (general internist vs geriatrician).

We analyzed data using the Wilcoxon rank-sum test because the data were not normally distributed. We used SAS Statistical Software (SAS Institute, Cary, NC). The University of Pennsylvania Institutional Review Board approved the study. The project was supported by a grant from the Bach Fund of the Presbyterian Medical Center, University of Pennsylvania.

Results

How did the physicians talk to their patient?

The 30 study physicians were primarily women, one fifth were from under-represented minorities, and one third were either residents or fellows (TABLE 2). Of 13 key informational points endorsed by our physician panel (TABLE 1), the physician-subjects addressed a mean of 6.7 points (range, 3–10). Nearly all physician-subjects discussed the value of colorectal cancer screening, colonoscopy as a standard colorectal screening procedure, and sedation during the procedure. However, fewer than 20% addressed the following topics: insurance/scheduling, dietary changes, medication modification, and risks of colonoscopy. In this small sample, the number of topics mentioned did not differ significantly by physician characteristic (TABLE 2).

Two thirds of the physicians asked the simulated patient about her prior knowledge or experience with colonoscopy. Although this question was not among the original 13 informational points, it helped to guide the discussion by identifying specific preconceptions or prior knowledge of this test. Therefore, this post hoc 14th informational point was added to our list but not considered in our analyses.

Gain-framed messages used more than loss-framed messages

Nearly all physicians used gain-framed messages, and more than half also used loss-framed messages (TABLE 3). Only 1 physician offered only a loss-framed message. Overall, study physicians mentioned less than 2 gain- or loss-framed messages.

• The most common types of gain-framed messages were detecting cancer early, preventing cancer by taking out polyps, and screening at only a 10-year interval if the test result is negative.
• The most common loss-framed messages noted that colorectal cancer was the second most common cause of cancer death and that risk is increased with a family history of this cancer.

TABLE 3
Gain- and loss-framed messages and types of numeracy information used by study physicians

TYPE OF MESSAGE OR NUMERACY	PHYSICIANS N (%)	OCCURRENCES IN INTERVIEWS, Total N (MEAN AMONG USERS, RANGE)
Message framing
Gain-framed	29 (96)	56 (1.9, 1–5)
Loss-framed	20 (67)	31 (1.6, 1–3)
Numeracy
Descriptive terms	19 (63)	36 (1.9, 1–3)
Statistical terms	15 (50)	30 (2.0, 1–5)
Temporal terms	9 (30)	11 (1.2, 1–2)
Proportions	4 (13)	5 (1.3, 1–2)
Fractions	3 (10)	3 (1.0, 1–1)

Physicians avoided using numbers

Of the 15 types of numeracy information described by Ahlers-Schmit et al, our physicians used only 5. Nineteen physicians (63%) used descriptive terms such as “likely” or “increased,” and 15 (50%) used statistical concepts such as risk and second-most-common cause. Physicians avoided using numbers; 9 (30%) used temporal terms such as “early”; 4 (13%) cited a proportion; and only 3 (10%) used a fraction.

Colloquial language, or was it crude?

While reading the transcripts, we noted that some physicians used colloquial terms that could be regarded as crude. Other terms were probably too technical without an explanation. Some information was simply incorrect. We offer selected quotes to illustrate various types of language used.

About the prep:

• “Getting a colonoscopy is not the most fun experience…you have really bad diarrhea and you just empty out your guts.”
• “It’s basically Liquid Plumber for your bowels.”
• “Bowel prep…is kind of voluminous and associated with kind of massive bowel movements.”
• “Everybody hates the prep and you may be one of those and that’s just that.”
• “Generally you have to be up all night, sometimes, cleaning your bowels out.”

About the procedure:

• “It’s not the most comfortable screening exam in the world.”
• “It’s a test where they stick a lighted tube up your back-side.”
• “The stomach doctors put a camera up your bottom and look at the walls of your colon.”
• “They can go in with a microscope and look around and look at the colon itself.”
• “It’s a painless test.”

Word polyp is used, but not defined

Physicians often employed technical language when describing the pathology detected by colonoscopy. “Polyp” was mentioned by 20 physicians (67%) but rarely defined; “biopsy” by 5 (17%), and “lesion” by 6 (20%). Other technical terms were precancerous, symptomatic, and incapacitated.

 

Discussion

An informed patient is a willing patient

Our study physicians addressed only half of the 13 informational points, likely reflecting the time constraints of a typical office visit. Primary care physicians appear to expect that either the colonoscopist or other sources of information would fill in the gaps. As reported in several studies, unanswered questions can discourage patients from keeping their scheduled colonoscopy appointment.^10,11 In one report of African-American church members, those with adequate knowledge about colorectal cancer screening were more likely to complete screening.²⁴

Wolf and Becker suggested that discussions about cancer screening address 4 broad topics: the probability of developing the cancer, the operating characteristics of the screening test(s), the likelihood that screening will benefit the patient, and potential burdens of the test.²⁵ Instead of a balanced and lengthy discussion, our study physicians generally emphasized the positives such as the value of avoiding colon cancer, the standard nature of this test, and the benefit of being sedated for the procedure. Thus, gain-framed messages about colorectal cancer were the norm for our study physicians.

Half of the physicians also offered loss-framed messages emphasizing the need to avoid the consequences of colorectal cancer and the increased threat associated with a family history of this malignancy. Research in mammography screening suggests that loss-framed messaging may be a more powerful motivator than gain-framed messaging,²⁶ but it is not clear if this observation can be generalized to colorectal cancer screening.

Walking a fine line with the particulars of risk

Our study physicians rarely provided data on the probability of developing colorectal cancer. Physicians may avoid this topic because many patients have difficulty understanding information about the risk of colorectal cancer.¹¹ In support of this approach, Lipkus and colleagues reported that various ways of informing patients about colorectal cancer risk did not affect their intention to be screened.²⁷ Of concern, most of our physicians did not address the common misconception that colorectal cancer screening is unnecessary in the absence of symptoms.²⁸

Overall, the level of numeracy information provided by study physicians required minimal patient understanding of mathematical and statistical concepts. Most information was descriptive, such as colonoscopy being “more thorough” than other tests. Though statistical concepts such as “risk” were often mentioned, few physicians offered probabilities or incidence data. Experts recommend providing such data,²⁵ but Web sites have been criticized for offering excessive numerical cancer risk data.²² Therefore, physicians must walk a fine line between providing adequate information and offering data that require a high level of health numeracy for understanding.

6 key points physicians often overlook

Most physicians failed to mention dietary and medication changes, scheduling/insurance coverage issues, and risk of complications from colonoscopy. Nearly 60% failed to discuss the patient’s risk of colorectal cancer. Almost half did not mention the need for a companion to accompany the patient after the test. Scheduling challenges, in particular, are known to interfere with completing colonoscopy.¹¹

Many neglect to describe the procedure

Thirty percent of physicians failed to describe the procedure itself, so it is not surprising that patients complain they have a poor understanding of test logistics.^11,29,30 Denberg and colleagues have reported that mailing an informational brochure about colonoscopy can increase the number who keep their appointment.³¹

How language choices may affect understanding

Other researchers have identified additional patient barriers to colonoscopy, including fear of pain, concern for modesty, and desire to avoid the bowel prep.^11,32 These concerns may be mitigated or heightened by the physician’s language. In our review of transcripts, physicians often used slang or colloquial language to describe the procedure, probably in an attempt to convey information in a familiar way. This language may be viewed as crude and potentially discouraging, but further research is needed to evaluate patient receptiveness to different ways of speaking about sensitive topics.

Additionally, physicians commonly used technical terms such as “polyp” and “biopsy” without explaining them. Technical language may increase racial disparities in adhering to scheduled colonoscopy. In a family medicine clinic, patients from minority groups had particular difficulty understanding medical terms and procedure names.²⁸ Because little time is available for counseling about cancer screening tests, and because patients retain only a limited amount of information about procedures,³³ supplementary informational sources are warranted.^15-17,31 Options include brochures, telephone calls, letters, e-mails, Web site data, and videotapes, but it is unclear which sources optimally improve patient adherence to screening colonoscopy.³⁴

 

Study limitations include simulated interaction

There were a number of limitations to this study. First, the investigators “simulated” the patient. Though study physicians were told to act as if they were speaking to a regular patient, they may still have unconsciously modified their usual approach to addressing this topic.

Second, we did not assess the effectiveness of these discussions in motivating actual patients to receive colonoscopy.

Other limitations included the following:

• We did not set a time period for these discussions, so they may have been even more limited in actual practice.
• We studied physicians from a single health care setting wherein colonoscopy appears to be the preferred approach to screen an average risk patient for colorectal cancer. In addition, in this health care system, this test is performed by a gastroenterologist, rather than a primary care physician.
• We did not determine whether patients regard our selected quotes as too colloquial or technical.
• This study did not address the important barrier of a physician forgetting to recommend colorectal cancer screening.³⁵

Further research, next steps

Our study supports the hypothesis that physicians differ widely—but are generally deficient—when informing patients about screening colonoscopy. They generally emphasize the positives of colonoscopy and use terms that are colloquial, avoiding statistical concepts that may be hard for patients to understand. Future studies need to address the effectiveness of these approaches to discussing screening colonoscopy.

Given the central role of the primary care physician in motivating patients to undergo screening colonoscopy in a limited time period, it appears that additional supports are needed to supplement physician discussion about this important preventive care procedure.

Correspondence
Barbara J. Turner MD, MSEd, University of Pennsylvania, 1123 Blockley Hall/6021, 423 Guardian Drive, Philadelphia, PA 19104; bturner@mail.med.upenn.edu

At the insistence of her family, a woman comes to you complaining of a cough that has lasted several weeks. Many experts would urge a thorough diagnostic investigation, justifying this action with a presumed shorter course of treatment. But is an involved work-up really necessary? Would a quicker, less expensive approach serve the patient just as well? We designed our study to answer these questions.

“Test all, then treat” is expensive

In the management of patients with chronic cough, most algorithms have advocated the approach of “test all, then treat.”^1-6 This is an expensive approach and one that delays relief for the patient, though a confirmative diagnosis may decrease the overall duration of treatment. In most cases, however, this approach may be unnecessary. And because few of the underlying disorders are acutely debilitating or rapidly progressive, even misdiagnosis and resultant inappropriate treatment pose little risk to patients.

The less common approach is a sequence of trial-and-error treatments based on a presumptive hierarchy of possible diagnoses.⁶ The advantage with this strategy is a 3-to 5-fold cost savings.⁶ And we suspected that the associated length of treatment would be acceptable.

We proposed that the management of patients with chronic cough begin with a presumptive diagnosis, thus simplifying the initial evaluation, keeping costs low, and offering earlier treatment.

We developed an algorithm for the treatment of patients with chronic cough that relies on minimal diagnostic investigations, regardless of the confirmed diagnosis. We evaluated our approach from the perspectives of the presumptive diagnosis and the therapeutic response period.

Methods

Treatment algorithm reflects experience and local resources

Initially, we designed the algorithm to follow findings in the literature on the treatment of patients with chronic cough. We then simplified and modified the algorithm to reflect the experiences of doctors from the pulmonology clinic in our hospital, and to take into account local patient characteristics and available medical equipment and resources.

Subjects were otherwise healthy

Between January 1 and December 31, 2005, at the internal medicine clinic of Cheju National University Hospital, we enrolled 378 patients whose chief complaint was cough persisting for more than 4 weeks and who had no abnormalities detected on auscultation by a physician, chest radiography (posterior–anterior view and left lateral view), or complete blood cell counts. Each patient had a complete blood count to detect anemia, hematologic disorders, or inflammatory conditions. Current users of angiotensin-converting enzyme (ACE) inhibitors were excluded.

All of the patients we enrolled were adults living in Jeju, Korea, and the mean age was 51 years. One hundred eighty-six (49%) were men. The median reported cough duration was 2 months (range, 1–36 months) (TABLE 1).

We instructed the patients on our algorithmic approach to treating chronic cough and encouraged them to follow the algorithm through to telephone notification of the next visit.

TABLE 1
Characteristics of the 378 enrolled patients

Men/women	186/192 (49/51%)
Age, years	51.2±16.12
Cough duration in months, median (range)	2 (1–36)

How we determined treatment outcomes

Patients graded their cough severity subjectively at each visit using a visual analogue scale (VAS) from 1 (no cough at all) to 10 (cough severity same as that remembered during first visit to the clinic). We recorded their reports on a questionnaire.

Successful responders were patients who reported a subjective grade of cough severity less than 3. Partial responders and nonresponders were defined, respectively, as those reporting VAS scores from 3 to 6 and more than 6.

We defined the response period as the number of days from enrollment until the next visit in which the patient first reported a VAS score of cough severity less than 3.

Algorithm: Addressing the 3 most common causes of chronic cough

 

1. Postnasal drip syndrome. Patients first underwent a rhinoscopic examination (FIGURE). When clinicians detected redness or abnormal discharge on the nasal mucosa, they prescribed a 5-day course of antihistamine (10 mg/day ebastine [Ebastel] orally), pseudoephedrine (30 mg 3 times daily, orally), and intranasal corticosteroid (triamcinolone acetonide [Nasacort] 110 mcg twice daily intranasally). Patients without symptoms of rhinitis were referred to the next diagnostic phase.

With completion of the prescribed medication 5 days after the first visit, we graded the severity of cough by questionnaire. Patients in the successful and partial responder categories received a presumptive diagnosis of postnasal drip syndrome, and we asked them to continue using the medication for at least 2 weeks. We had each nonresponder stop the medication.

2. Asthma syndrome. Partial responder and nonresponder patients entered the next diagnostic phase: a methacholine bronchial provocation test (MPT)⁷ and eosinophil count with induced sputum by hypertonic saline (3% NaCl).⁸ We defined a positive MPT result as <10 mg/ mL of methacholine causing a 20% fall in FEV₁ from baseline (PC₂₀). Patients with more than 3% eosinophils in the induced sputum specimen or with a positive MPT received a 1-week prescription for inhaled budesonide 160 mcg twice daily and inhaled formoterol (Symbicort) 4.5 mcg twice daily. Patients who did not exhibit these asthma indicators were referred to the next step.

At the next visit, we again graded the severity of cough. Patients in the successful and partial responder categories received a presumptive diagnosis of asthma syndrome. We asked successful and partial responders to continue the medication for at least 2 weeks. Those classed as nonresponders were asked to stop their medication. We referred all patients with positive MPT test results to a special clinic for asthma, regardless of responses to this therapeutic trial or eosinophil count in the induced sputum.

3. Reflux syndrome. Partial responders and nonresponders then received a 2-week prescription for a proton pump inhibitor, pantoprazole (Pantoloc), 40 mg orally once daily.⁹ At the next visit 2 weeks later, we graded the severity of cough. Successful and partial responders were given a presumptive diagnosis of reflux syndrome, but only successful responders were asked to continue the same medication for at least 6 weeks. At the discretion of their physicians, partial and nonresponders underwent other diagnostic investigations, including high-resolution computerized tomography (CT) of the lungs, bronchoscopic examination, sputum smear and culture for acid fast bacilli, sputum culture for ordinary bacteria and fungi, and a serological test for human immunodeficiency virus.

FIGURE
A presumptive-diagnosis algorithm

Chronic cough resolved for more than 90% of patients treated according to this algorithm.
MPT, methacholine bronchial provocation test; VAS, visual analog scale.

Results

Presumptive diagnoses

Among 378 patients, 346 (91%) showed erythematous mucosa or abnormal discharge in rhinoscopic examinations and received empiric medication for 5 days. The successful-responder category included 176 patients (47%); 79 (21%) were classed as partial responders, and 255 (67%) received the presumptive diagnosis of postnasal drip syndrome. Among the 346 treated patients, 91 (24% of those enrolled, or 26% of treated) showed no response.

Thirty-two patients with normal rhinoscopic findings and 170 categorized as partial or nonresponders in the first step underwent an MPT and eosinophil count of induced sputum. One hundred forty-four showed positive results and received empiric treatment for 1 week. Among these, 141 were deemed successful responders (37% of enrolled, or 98% of treated), 3 partial responders (1% of enrolled, or 2% of treated), and none were nonresponders.

In all, 61 patients had empiric treatment for reflux syndrome for 2 weeks; 58 had normal findings for both the MPT and sputum eosinophil count, and 3 were classified as partial responders in the previous therapeutic trial. Twenty-nine patients (8% of enrolled, or 47% of treated) were classified as successful responders after 2 weeks (TABLE 2).

TABLE 2
Presumptive diagnoses corresponded to expected frequency (and occasionally co-existed)

DIAGNOSIS	NO. OF PATIENTS (%)* N=378
Postnasal drip syndrome	255 (67.5)
Asthma syndrome	144 (38.1)
Reflux syndrome	29 (7.7)
CO-EXISTING PATHOLOGIES	82 (21.7)
Postnasal drip syndrome and asthma syndrome	52 (13.8)
Postnasal drip syndrome and reflux syndrome	7 (1.9)
Postnasal drip syndrome and other diagnosis	20 (5.3)
Asthma syndrome and other diagnosis	3 (0.8)
* The percentage of patients under "Diagnosis" does not add up to 100% because some patients had more than one condition, accounted for under "Co-existing pathologies."

Therapeutic response period for successful responders

Within 5 days of beginning the course determined by the algorithm (Figure), 176 patients (47%) who received treatment for presumed postnasal drip syndrome experienced resolution of their chronic cough.

 

Another 141 patients (37%) diagnosed with asthma syndrome (with or without postnasal drip syndrome) reported cough resolution following successful treatment between 7 and 12 days.

Another 29 patients (8%) with re-flux syndrome were successfully treated between 14 and 26 days.

Treatment of chronic cough by the algorithm

After application of the therapeutic algorithm, the chronic cough of 346 patients (92%) resolved. Thirty-two patients (8.5%) underwent other diagnostic investigations.

Final diagnoses after further diagnostic testing

Ten patients reported that they stopped coughing spontaneously while awaiting additional diagnostic investigations. Seven patients had mycobacterial infections confirmed by acid fast bacilli smears or culture of sputum or bronchoscopic washings. Six patients had localized or diffuse bronchiectasis confirmed by high-resolution CT, the results of which were used retrospectively to reassess normal or equivocal findings in the initial diagnostic investigations. Finally, the coughs of 12 patients were judged to be idiopathic or psychogenic.

Discussion

Cough is a symptom not easily assessed objectively. Previous studies measured severity of cough with daily diaries and visual analog scales, which are subjective measurement tools. We, too, used the visual analog scale to measure cough severity and treatment response. We did not pursue a definitive diagnosis of the cause of chronic cough. Rather, our algorithmic approach made presumptive diagnoses that were confirmed or refuted by patients’ successive reports of cough severity in response to treatment.

The logic behind our algorithm

Because studies in Korea have shown that postnasal drip is the most frequent cause of chronic cough, we chose rhinoscopy as the first diagnostic investigation. The second and third steps of our approach investigated asthma syndrome and reflux syndrome, respectively.

We did not take into account whether patients smoked cigarettes. Some investigators rightly point out that smoking might contribute to chronic cough. However, we have not met many smokers willing to quit because of a cough, and our algorithm is designed for practical clinical use. In contrast, patients with chronic cough secondary to ACE inhibitor therapy have readily accepted trials of different antihypertensive medications.

Our assumptions proved true

Patients with any abnormality of the nasal mucosa were treated for postnasal drip syndrome. Though the proportion of abnormal mucosal findings was greater than that reported in previous investigations of the same ethnic subjects, the eventual treatment response showed that the presumptive diagnosis of postnasal drip was equivalent to that in other studies.^10,11

Postnasal drip syndrome did indeed turn out to be the most common presumptive cause of cough in our study. However, roughly one third of these patients proved to have an additional presumptive disorder. Previous investigations have also reported dual or multiple pathologies in patients with a chronic cough.^11,12

If treatment succeeded at any step in our algorithm, we asked patients to stop taking medication—with the exception of those who had positive results on methacholine bronchial provocation test. Asthma is a chronic inflammatory disorder that needs persistent therapy to prevent exacerbations and declining lung function.^13,14 Challenge studies with methacholine or histamine are sensitive tests and provide high negative predictive values for the diagnosis of asthma and cough variant asthma.^15,16

What have other studies shown?

The natural course of chronic cough is still in question, primarily because of the heterogeneity of its etiology. The natural course of many common diseases has been investigated, of course, but few studies have focused on duration of symptoms such as cough. Park et al¹⁷ investigated the natural course of eosinophilic bronchitis, a common underlying disorder in chronic cough. In a 48-month follow-up of 36 patients diagnosed with eosinophilic bronchitis, 14% experienced recurrence after treatment. And patients with a higher percentage of eosinophils in the sputum had a risk for developing airway hyperresponsiveness.

Ours et al⁹ reported that, for patients without asthma or postnasal drip, an empiric 2-week trial of high-dose proton pump inhibitors was more reliable and cost effective for chronic cough than was treatment after esophageal manometry or 24 hours dual probe pH monitoring. Besides the expense of manometry and pH monitoring, both procedures are invasive and unavailable in many localities such as ours. Our algorithm supposes, for one thing, minimum availability of medical equipment in many locales.

The algorithm makes sense

Our approach decreased medical expenses and therapeutic response periods. Cough resolved for more than 90% of our patients. This success rate was equivalent to that reported by previous studies, most of which revealed no definitive diagnosis during the therapeutic response period.^2-4,18 Half of all patients in our study experienced cough resolution within 5 days, and more than 80% did so within 12 days.

 

Development of algorithms similar to ours should take into account not just findings in the literature but the experiences of local doctors and available medical equipment and options.

At the insistence of her family, a woman comes to you complaining of a cough that has lasted several weeks. Many experts would urge a thorough diagnostic investigation, justifying this action with a presumed shorter course of treatment. But is an involved work-up really necessary? Would a quicker, less expensive approach serve the patient just as well? We designed our study to answer these questions.

“Test all, then treat” is expensive

In the management of patients with chronic cough, most algorithms have advocated the approach of “test all, then treat.”^1-6 This is an expensive approach and one that delays relief for the patient, though a confirmative diagnosis may decrease the overall duration of treatment. In most cases, however, this approach may be unnecessary. And because few of the underlying disorders are acutely debilitating or rapidly progressive, even misdiagnosis and resultant inappropriate treatment pose little risk to patients.

The less common approach is a sequence of trial-and-error treatments based on a presumptive hierarchy of possible diagnoses.⁶ The advantage with this strategy is a 3-to 5-fold cost savings.⁶ And we suspected that the associated length of treatment would be acceptable.

We proposed that the management of patients with chronic cough begin with a presumptive diagnosis, thus simplifying the initial evaluation, keeping costs low, and offering earlier treatment.

We developed an algorithm for the treatment of patients with chronic cough that relies on minimal diagnostic investigations, regardless of the confirmed diagnosis. We evaluated our approach from the perspectives of the presumptive diagnosis and the therapeutic response period.

Methods

Treatment algorithm reflects experience and local resources

Initially, we designed the algorithm to follow findings in the literature on the treatment of patients with chronic cough. We then simplified and modified the algorithm to reflect the experiences of doctors from the pulmonology clinic in our hospital, and to take into account local patient characteristics and available medical equipment and resources.

Subjects were otherwise healthy

Between January 1 and December 31, 2005, at the internal medicine clinic of Cheju National University Hospital, we enrolled 378 patients whose chief complaint was cough persisting for more than 4 weeks and who had no abnormalities detected on auscultation by a physician, chest radiography (posterior–anterior view and left lateral view), or complete blood cell counts. Each patient had a complete blood count to detect anemia, hematologic disorders, or inflammatory conditions. Current users of angiotensin-converting enzyme (ACE) inhibitors were excluded.

All of the patients we enrolled were adults living in Jeju, Korea, and the mean age was 51 years. One hundred eighty-six (49%) were men. The median reported cough duration was 2 months (range, 1–36 months) (TABLE 1).

We instructed the patients on our algorithmic approach to treating chronic cough and encouraged them to follow the algorithm through to telephone notification of the next visit.

TABLE 1
Characteristics of the 378 enrolled patients

Men/women	186/192 (49/51%)
Age, years	51.2±16.12
Cough duration in months, median (range)	2 (1–36)

How we determined treatment outcomes

Patients graded their cough severity subjectively at each visit using a visual analogue scale (VAS) from 1 (no cough at all) to 10 (cough severity same as that remembered during first visit to the clinic). We recorded their reports on a questionnaire.

Successful responders were patients who reported a subjective grade of cough severity less than 3. Partial responders and nonresponders were defined, respectively, as those reporting VAS scores from 3 to 6 and more than 6.

We defined the response period as the number of days from enrollment until the next visit in which the patient first reported a VAS score of cough severity less than 3.

Algorithm: Addressing the 3 most common causes of chronic cough

 

1. Postnasal drip syndrome. Patients first underwent a rhinoscopic examination (FIGURE). When clinicians detected redness or abnormal discharge on the nasal mucosa, they prescribed a 5-day course of antihistamine (10 mg/day ebastine [Ebastel] orally), pseudoephedrine (30 mg 3 times daily, orally), and intranasal corticosteroid (triamcinolone acetonide [Nasacort] 110 mcg twice daily intranasally). Patients without symptoms of rhinitis were referred to the next diagnostic phase.

With completion of the prescribed medication 5 days after the first visit, we graded the severity of cough by questionnaire. Patients in the successful and partial responder categories received a presumptive diagnosis of postnasal drip syndrome, and we asked them to continue using the medication for at least 2 weeks. We had each nonresponder stop the medication.

2. Asthma syndrome. Partial responder and nonresponder patients entered the next diagnostic phase: a methacholine bronchial provocation test (MPT)⁷ and eosinophil count with induced sputum by hypertonic saline (3% NaCl).⁸ We defined a positive MPT result as <10 mg/ mL of methacholine causing a 20% fall in FEV₁ from baseline (PC₂₀). Patients with more than 3% eosinophils in the induced sputum specimen or with a positive MPT received a 1-week prescription for inhaled budesonide 160 mcg twice daily and inhaled formoterol (Symbicort) 4.5 mcg twice daily. Patients who did not exhibit these asthma indicators were referred to the next step.

At the next visit, we again graded the severity of cough. Patients in the successful and partial responder categories received a presumptive diagnosis of asthma syndrome. We asked successful and partial responders to continue the medication for at least 2 weeks. Those classed as nonresponders were asked to stop their medication. We referred all patients with positive MPT test results to a special clinic for asthma, regardless of responses to this therapeutic trial or eosinophil count in the induced sputum.

3. Reflux syndrome. Partial responders and nonresponders then received a 2-week prescription for a proton pump inhibitor, pantoprazole (Pantoloc), 40 mg orally once daily.⁹ At the next visit 2 weeks later, we graded the severity of cough. Successful and partial responders were given a presumptive diagnosis of reflux syndrome, but only successful responders were asked to continue the same medication for at least 6 weeks. At the discretion of their physicians, partial and nonresponders underwent other diagnostic investigations, including high-resolution computerized tomography (CT) of the lungs, bronchoscopic examination, sputum smear and culture for acid fast bacilli, sputum culture for ordinary bacteria and fungi, and a serological test for human immunodeficiency virus.

FIGURE
A presumptive-diagnosis algorithm

Chronic cough resolved for more than 90% of patients treated according to this algorithm.
MPT, methacholine bronchial provocation test; VAS, visual analog scale.

Results

Presumptive diagnoses

Among 378 patients, 346 (91%) showed erythematous mucosa or abnormal discharge in rhinoscopic examinations and received empiric medication for 5 days. The successful-responder category included 176 patients (47%); 79 (21%) were classed as partial responders, and 255 (67%) received the presumptive diagnosis of postnasal drip syndrome. Among the 346 treated patients, 91 (24% of those enrolled, or 26% of treated) showed no response.

Thirty-two patients with normal rhinoscopic findings and 170 categorized as partial or nonresponders in the first step underwent an MPT and eosinophil count of induced sputum. One hundred forty-four showed positive results and received empiric treatment for 1 week. Among these, 141 were deemed successful responders (37% of enrolled, or 98% of treated), 3 partial responders (1% of enrolled, or 2% of treated), and none were nonresponders.

In all, 61 patients had empiric treatment for reflux syndrome for 2 weeks; 58 had normal findings for both the MPT and sputum eosinophil count, and 3 were classified as partial responders in the previous therapeutic trial. Twenty-nine patients (8% of enrolled, or 47% of treated) were classified as successful responders after 2 weeks (TABLE 2).

TABLE 2
Presumptive diagnoses corresponded to expected frequency (and occasionally co-existed)

DIAGNOSIS	NO. OF PATIENTS (%)* N=378
Postnasal drip syndrome	255 (67.5)
Asthma syndrome	144 (38.1)
Reflux syndrome	29 (7.7)
CO-EXISTING PATHOLOGIES	82 (21.7)
Postnasal drip syndrome and asthma syndrome	52 (13.8)
Postnasal drip syndrome and reflux syndrome	7 (1.9)
Postnasal drip syndrome and other diagnosis	20 (5.3)
Asthma syndrome and other diagnosis	3 (0.8)
* The percentage of patients under "Diagnosis" does not add up to 100% because some patients had more than one condition, accounted for under "Co-existing pathologies."

Therapeutic response period for successful responders

Within 5 days of beginning the course determined by the algorithm (Figure), 176 patients (47%) who received treatment for presumed postnasal drip syndrome experienced resolution of their chronic cough.

 

Another 141 patients (37%) diagnosed with asthma syndrome (with or without postnasal drip syndrome) reported cough resolution following successful treatment between 7 and 12 days.

Another 29 patients (8%) with re-flux syndrome were successfully treated between 14 and 26 days.

Treatment of chronic cough by the algorithm

After application of the therapeutic algorithm, the chronic cough of 346 patients (92%) resolved. Thirty-two patients (8.5%) underwent other diagnostic investigations.

Final diagnoses after further diagnostic testing

Ten patients reported that they stopped coughing spontaneously while awaiting additional diagnostic investigations. Seven patients had mycobacterial infections confirmed by acid fast bacilli smears or culture of sputum or bronchoscopic washings. Six patients had localized or diffuse bronchiectasis confirmed by high-resolution CT, the results of which were used retrospectively to reassess normal or equivocal findings in the initial diagnostic investigations. Finally, the coughs of 12 patients were judged to be idiopathic or psychogenic.

Discussion

Cough is a symptom not easily assessed objectively. Previous studies measured severity of cough with daily diaries and visual analog scales, which are subjective measurement tools. We, too, used the visual analog scale to measure cough severity and treatment response. We did not pursue a definitive diagnosis of the cause of chronic cough. Rather, our algorithmic approach made presumptive diagnoses that were confirmed or refuted by patients’ successive reports of cough severity in response to treatment.

The logic behind our algorithm

Because studies in Korea have shown that postnasal drip is the most frequent cause of chronic cough, we chose rhinoscopy as the first diagnostic investigation. The second and third steps of our approach investigated asthma syndrome and reflux syndrome, respectively.

We did not take into account whether patients smoked cigarettes. Some investigators rightly point out that smoking might contribute to chronic cough. However, we have not met many smokers willing to quit because of a cough, and our algorithm is designed for practical clinical use. In contrast, patients with chronic cough secondary to ACE inhibitor therapy have readily accepted trials of different antihypertensive medications.

Our assumptions proved true

Patients with any abnormality of the nasal mucosa were treated for postnasal drip syndrome. Though the proportion of abnormal mucosal findings was greater than that reported in previous investigations of the same ethnic subjects, the eventual treatment response showed that the presumptive diagnosis of postnasal drip was equivalent to that in other studies.^10,11

Postnasal drip syndrome did indeed turn out to be the most common presumptive cause of cough in our study. However, roughly one third of these patients proved to have an additional presumptive disorder. Previous investigations have also reported dual or multiple pathologies in patients with a chronic cough.^11,12

If treatment succeeded at any step in our algorithm, we asked patients to stop taking medication—with the exception of those who had positive results on methacholine bronchial provocation test. Asthma is a chronic inflammatory disorder that needs persistent therapy to prevent exacerbations and declining lung function.^13,14 Challenge studies with methacholine or histamine are sensitive tests and provide high negative predictive values for the diagnosis of asthma and cough variant asthma.^15,16

What have other studies shown?

The natural course of chronic cough is still in question, primarily because of the heterogeneity of its etiology. The natural course of many common diseases has been investigated, of course, but few studies have focused on duration of symptoms such as cough. Park et al¹⁷ investigated the natural course of eosinophilic bronchitis, a common underlying disorder in chronic cough. In a 48-month follow-up of 36 patients diagnosed with eosinophilic bronchitis, 14% experienced recurrence after treatment. And patients with a higher percentage of eosinophils in the sputum had a risk for developing airway hyperresponsiveness.

Ours et al⁹ reported that, for patients without asthma or postnasal drip, an empiric 2-week trial of high-dose proton pump inhibitors was more reliable and cost effective for chronic cough than was treatment after esophageal manometry or 24 hours dual probe pH monitoring. Besides the expense of manometry and pH monitoring, both procedures are invasive and unavailable in many localities such as ours. Our algorithm supposes, for one thing, minimum availability of medical equipment in many locales.

The algorithm makes sense

Our approach decreased medical expenses and therapeutic response periods. Cough resolved for more than 90% of our patients. This success rate was equivalent to that reported by previous studies, most of which revealed no definitive diagnosis during the therapeutic response period.^2-4,18 Half of all patients in our study experienced cough resolution within 5 days, and more than 80% did so within 12 days.

 

Development of algorithms similar to ours should take into account not just findings in the literature but the experiences of local doctors and available medical equipment and options.

At the insistence of her family, a woman comes to you complaining of a cough that has lasted several weeks. Many experts would urge a thorough diagnostic investigation, justifying this action with a presumed shorter course of treatment. But is an involved work-up really necessary? Would a quicker, less expensive approach serve the patient just as well? We designed our study to answer these questions.

“Test all, then treat” is expensive

In the management of patients with chronic cough, most algorithms have advocated the approach of “test all, then treat.”^1-6 This is an expensive approach and one that delays relief for the patient, though a confirmative diagnosis may decrease the overall duration of treatment. In most cases, however, this approach may be unnecessary. And because few of the underlying disorders are acutely debilitating or rapidly progressive, even misdiagnosis and resultant inappropriate treatment pose little risk to patients.

The less common approach is a sequence of trial-and-error treatments based on a presumptive hierarchy of possible diagnoses.⁶ The advantage with this strategy is a 3-to 5-fold cost savings.⁶ And we suspected that the associated length of treatment would be acceptable.

We proposed that the management of patients with chronic cough begin with a presumptive diagnosis, thus simplifying the initial evaluation, keeping costs low, and offering earlier treatment.

We developed an algorithm for the treatment of patients with chronic cough that relies on minimal diagnostic investigations, regardless of the confirmed diagnosis. We evaluated our approach from the perspectives of the presumptive diagnosis and the therapeutic response period.

Methods

Treatment algorithm reflects experience and local resources

Initially, we designed the algorithm to follow findings in the literature on the treatment of patients with chronic cough. We then simplified and modified the algorithm to reflect the experiences of doctors from the pulmonology clinic in our hospital, and to take into account local patient characteristics and available medical equipment and resources.

Subjects were otherwise healthy

Between January 1 and December 31, 2005, at the internal medicine clinic of Cheju National University Hospital, we enrolled 378 patients whose chief complaint was cough persisting for more than 4 weeks and who had no abnormalities detected on auscultation by a physician, chest radiography (posterior–anterior view and left lateral view), or complete blood cell counts. Each patient had a complete blood count to detect anemia, hematologic disorders, or inflammatory conditions. Current users of angiotensin-converting enzyme (ACE) inhibitors were excluded.

All of the patients we enrolled were adults living in Jeju, Korea, and the mean age was 51 years. One hundred eighty-six (49%) were men. The median reported cough duration was 2 months (range, 1–36 months) (TABLE 1).

We instructed the patients on our algorithmic approach to treating chronic cough and encouraged them to follow the algorithm through to telephone notification of the next visit.

TABLE 1
Characteristics of the 378 enrolled patients

Men/women	186/192 (49/51%)
Age, years	51.2±16.12
Cough duration in months, median (range)	2 (1–36)

How we determined treatment outcomes

Patients graded their cough severity subjectively at each visit using a visual analogue scale (VAS) from 1 (no cough at all) to 10 (cough severity same as that remembered during first visit to the clinic). We recorded their reports on a questionnaire.

Successful responders were patients who reported a subjective grade of cough severity less than 3. Partial responders and nonresponders were defined, respectively, as those reporting VAS scores from 3 to 6 and more than 6.

We defined the response period as the number of days from enrollment until the next visit in which the patient first reported a VAS score of cough severity less than 3.

Algorithm: Addressing the 3 most common causes of chronic cough

 

1. Postnasal drip syndrome. Patients first underwent a rhinoscopic examination (FIGURE). When clinicians detected redness or abnormal discharge on the nasal mucosa, they prescribed a 5-day course of antihistamine (10 mg/day ebastine [Ebastel] orally), pseudoephedrine (30 mg 3 times daily, orally), and intranasal corticosteroid (triamcinolone acetonide [Nasacort] 110 mcg twice daily intranasally). Patients without symptoms of rhinitis were referred to the next diagnostic phase.

With completion of the prescribed medication 5 days after the first visit, we graded the severity of cough by questionnaire. Patients in the successful and partial responder categories received a presumptive diagnosis of postnasal drip syndrome, and we asked them to continue using the medication for at least 2 weeks. We had each nonresponder stop the medication.

2. Asthma syndrome. Partial responder and nonresponder patients entered the next diagnostic phase: a methacholine bronchial provocation test (MPT)⁷ and eosinophil count with induced sputum by hypertonic saline (3% NaCl).⁸ We defined a positive MPT result as <10 mg/ mL of methacholine causing a 20% fall in FEV₁ from baseline (PC₂₀). Patients with more than 3% eosinophils in the induced sputum specimen or with a positive MPT received a 1-week prescription for inhaled budesonide 160 mcg twice daily and inhaled formoterol (Symbicort) 4.5 mcg twice daily. Patients who did not exhibit these asthma indicators were referred to the next step.

At the next visit, we again graded the severity of cough. Patients in the successful and partial responder categories received a presumptive diagnosis of asthma syndrome. We asked successful and partial responders to continue the medication for at least 2 weeks. Those classed as nonresponders were asked to stop their medication. We referred all patients with positive MPT test results to a special clinic for asthma, regardless of responses to this therapeutic trial or eosinophil count in the induced sputum.

3. Reflux syndrome. Partial responders and nonresponders then received a 2-week prescription for a proton pump inhibitor, pantoprazole (Pantoloc), 40 mg orally once daily.⁹ At the next visit 2 weeks later, we graded the severity of cough. Successful and partial responders were given a presumptive diagnosis of reflux syndrome, but only successful responders were asked to continue the same medication for at least 6 weeks. At the discretion of their physicians, partial and nonresponders underwent other diagnostic investigations, including high-resolution computerized tomography (CT) of the lungs, bronchoscopic examination, sputum smear and culture for acid fast bacilli, sputum culture for ordinary bacteria and fungi, and a serological test for human immunodeficiency virus.

FIGURE
A presumptive-diagnosis algorithm

Chronic cough resolved for more than 90% of patients treated according to this algorithm.
MPT, methacholine bronchial provocation test; VAS, visual analog scale.

Results

Presumptive diagnoses

Among 378 patients, 346 (91%) showed erythematous mucosa or abnormal discharge in rhinoscopic examinations and received empiric medication for 5 days. The successful-responder category included 176 patients (47%); 79 (21%) were classed as partial responders, and 255 (67%) received the presumptive diagnosis of postnasal drip syndrome. Among the 346 treated patients, 91 (24% of those enrolled, or 26% of treated) showed no response.

Thirty-two patients with normal rhinoscopic findings and 170 categorized as partial or nonresponders in the first step underwent an MPT and eosinophil count of induced sputum. One hundred forty-four showed positive results and received empiric treatment for 1 week. Among these, 141 were deemed successful responders (37% of enrolled, or 98% of treated), 3 partial responders (1% of enrolled, or 2% of treated), and none were nonresponders.

In all, 61 patients had empiric treatment for reflux syndrome for 2 weeks; 58 had normal findings for both the MPT and sputum eosinophil count, and 3 were classified as partial responders in the previous therapeutic trial. Twenty-nine patients (8% of enrolled, or 47% of treated) were classified as successful responders after 2 weeks (TABLE 2).

TABLE 2
Presumptive diagnoses corresponded to expected frequency (and occasionally co-existed)

DIAGNOSIS	NO. OF PATIENTS (%)* N=378
Postnasal drip syndrome	255 (67.5)
Asthma syndrome	144 (38.1)
Reflux syndrome	29 (7.7)
CO-EXISTING PATHOLOGIES	82 (21.7)
Postnasal drip syndrome and asthma syndrome	52 (13.8)
Postnasal drip syndrome and reflux syndrome	7 (1.9)
Postnasal drip syndrome and other diagnosis	20 (5.3)
Asthma syndrome and other diagnosis	3 (0.8)
* The percentage of patients under "Diagnosis" does not add up to 100% because some patients had more than one condition, accounted for under "Co-existing pathologies."

Therapeutic response period for successful responders

Within 5 days of beginning the course determined by the algorithm (Figure), 176 patients (47%) who received treatment for presumed postnasal drip syndrome experienced resolution of their chronic cough.

 

Another 141 patients (37%) diagnosed with asthma syndrome (with or without postnasal drip syndrome) reported cough resolution following successful treatment between 7 and 12 days.

Another 29 patients (8%) with re-flux syndrome were successfully treated between 14 and 26 days.

Treatment of chronic cough by the algorithm

After application of the therapeutic algorithm, the chronic cough of 346 patients (92%) resolved. Thirty-two patients (8.5%) underwent other diagnostic investigations.

Final diagnoses after further diagnostic testing

Ten patients reported that they stopped coughing spontaneously while awaiting additional diagnostic investigations. Seven patients had mycobacterial infections confirmed by acid fast bacilli smears or culture of sputum or bronchoscopic washings. Six patients had localized or diffuse bronchiectasis confirmed by high-resolution CT, the results of which were used retrospectively to reassess normal or equivocal findings in the initial diagnostic investigations. Finally, the coughs of 12 patients were judged to be idiopathic or psychogenic.

Discussion

Cough is a symptom not easily assessed objectively. Previous studies measured severity of cough with daily diaries and visual analog scales, which are subjective measurement tools. We, too, used the visual analog scale to measure cough severity and treatment response. We did not pursue a definitive diagnosis of the cause of chronic cough. Rather, our algorithmic approach made presumptive diagnoses that were confirmed or refuted by patients’ successive reports of cough severity in response to treatment.

The logic behind our algorithm

Because studies in Korea have shown that postnasal drip is the most frequent cause of chronic cough, we chose rhinoscopy as the first diagnostic investigation. The second and third steps of our approach investigated asthma syndrome and reflux syndrome, respectively.

We did not take into account whether patients smoked cigarettes. Some investigators rightly point out that smoking might contribute to chronic cough. However, we have not met many smokers willing to quit because of a cough, and our algorithm is designed for practical clinical use. In contrast, patients with chronic cough secondary to ACE inhibitor therapy have readily accepted trials of different antihypertensive medications.

Our assumptions proved true

Patients with any abnormality of the nasal mucosa were treated for postnasal drip syndrome. Though the proportion of abnormal mucosal findings was greater than that reported in previous investigations of the same ethnic subjects, the eventual treatment response showed that the presumptive diagnosis of postnasal drip was equivalent to that in other studies.^10,11

Postnasal drip syndrome did indeed turn out to be the most common presumptive cause of cough in our study. However, roughly one third of these patients proved to have an additional presumptive disorder. Previous investigations have also reported dual or multiple pathologies in patients with a chronic cough.^11,12

If treatment succeeded at any step in our algorithm, we asked patients to stop taking medication—with the exception of those who had positive results on methacholine bronchial provocation test. Asthma is a chronic inflammatory disorder that needs persistent therapy to prevent exacerbations and declining lung function.^13,14 Challenge studies with methacholine or histamine are sensitive tests and provide high negative predictive values for the diagnosis of asthma and cough variant asthma.^15,16

What have other studies shown?

The natural course of chronic cough is still in question, primarily because of the heterogeneity of its etiology. The natural course of many common diseases has been investigated, of course, but few studies have focused on duration of symptoms such as cough. Park et al¹⁷ investigated the natural course of eosinophilic bronchitis, a common underlying disorder in chronic cough. In a 48-month follow-up of 36 patients diagnosed with eosinophilic bronchitis, 14% experienced recurrence after treatment. And patients with a higher percentage of eosinophils in the sputum had a risk for developing airway hyperresponsiveness.

Ours et al⁹ reported that, for patients without asthma or postnasal drip, an empiric 2-week trial of high-dose proton pump inhibitors was more reliable and cost effective for chronic cough than was treatment after esophageal manometry or 24 hours dual probe pH monitoring. Besides the expense of manometry and pH monitoring, both procedures are invasive and unavailable in many localities such as ours. Our algorithm supposes, for one thing, minimum availability of medical equipment in many locales.

The algorithm makes sense

Our approach decreased medical expenses and therapeutic response periods. Cough resolved for more than 90% of our patients. This success rate was equivalent to that reported by previous studies, most of which revealed no definitive diagnosis during the therapeutic response period.^2-4,18 Half of all patients in our study experienced cough resolution within 5 days, and more than 80% did so within 12 days.

 

Development of algorithms similar to ours should take into account not just findings in the literature but the experiences of local doctors and available medical equipment and options.

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

It is unfortunate that such lawsuits are brought, and their presence may indicate many problems within the legal system. Although clinicians who do nothing wrong should not have to endure unnecessary and unfounded lawsuits (the issue of tort reform within the legal system is beyond the scope of this column), these cases prompt psychiatrists to consider ways to protect themselves from such claims. Some practices might help protect you from successful malpractice claims, but there are no guarantees.

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

States are split on which standard the courts must apply and in many areas, the standard of care is based on local—not state or national—practices.²

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

 

Regardless of the treatment used—even if the medication is “off-label” and not FDA-approved for a particular disorder or the dose is not within the FDA-approved dosing range—you should be able to document your rationale for using a medication and dosing by showing that it is part of good clinical practice.

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Then document in the patient’s chart that you had this discussion with the patient and obtained consent.

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Adverse side effects are possible with any number of medications. Clinicians might need to change assessments and monitoring practices as new information—such as FDA or pharmaceutical company reporting or new studies in professional journals—becomes available.

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

Plaintiffs cannot prove proximate cause if there is:

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

 

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

It is unfortunate that such lawsuits are brought, and their presence may indicate many problems within the legal system. Although clinicians who do nothing wrong should not have to endure unnecessary and unfounded lawsuits (the issue of tort reform within the legal system is beyond the scope of this column), these cases prompt psychiatrists to consider ways to protect themselves from such claims. Some practices might help protect you from successful malpractice claims, but there are no guarantees.

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

States are split on which standard the courts must apply and in many areas, the standard of care is based on local—not state or national—practices.²

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

 

Regardless of the treatment used—even if the medication is “off-label” and not FDA-approved for a particular disorder or the dose is not within the FDA-approved dosing range—you should be able to document your rationale for using a medication and dosing by showing that it is part of good clinical practice.

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Then document in the patient’s chart that you had this discussion with the patient and obtained consent.

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Adverse side effects are possible with any number of medications. Clinicians might need to change assessments and monitoring practices as new information—such as FDA or pharmaceutical company reporting or new studies in professional journals—becomes available.

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

Plaintiffs cannot prove proximate cause if there is:

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

 

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

It is unfortunate that such lawsuits are brought, and their presence may indicate many problems within the legal system. Although clinicians who do nothing wrong should not have to endure unnecessary and unfounded lawsuits (the issue of tort reform within the legal system is beyond the scope of this column), these cases prompt psychiatrists to consider ways to protect themselves from such claims. Some practices might help protect you from successful malpractice claims, but there are no guarantees.

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

States are split on which standard the courts must apply and in many areas, the standard of care is based on local—not state or national—practices.²

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

 

Regardless of the treatment used—even if the medication is “off-label” and not FDA-approved for a particular disorder or the dose is not within the FDA-approved dosing range—you should be able to document your rationale for using a medication and dosing by showing that it is part of good clinical practice.

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Then document in the patient’s chart that you had this discussion with the patient and obtained consent.

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Adverse side effects are possible with any number of medications. Clinicians might need to change assessments and monitoring practices as new information—such as FDA or pharmaceutical company reporting or new studies in professional journals—becomes available.

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

Plaintiffs cannot prove proximate cause if there is:

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

 

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

VIENNA—Long-term treatment with eculizumab, a recombinant humanized monoclonal antibody, significantly reduces the risk of thrombosis in patients with paroxysmal nocturnal hemoglobinuria (PNH), according to the results of a recent multicenter study.

Peter Hillmen, MD, of the Leeds Teaching Hospitals NHS Trust, reported the results of the study at the 12th Congress of the European Hematology Association in June 2007.

Dr Hillmen and colleagues prospectively examined the aggregate thromboembolism (TE) event rate in eculizumab-treated patients from 3 recent parent studies, as well as a subsequent common extension study. They compared those rates to the TE rate in the same patients’ pre-eculizumab treatment.

Eculizumab, which is designed to inhibit activation of terminal complement components that have been implicated in the development of PNH, reduced the TE rate in each of the three parent studies.

Most importantly, the aggregate TE event rate during eculizumab treatment was significantly reduced by 85% (P=<0.001), when compared with the same patients before eculizumab treatment.

With restriction of the pretreatment observation period to the 12 months immediately preceding eculizumab treatment, the TE event rate during treatment was reduced by 94% (P=0.002). The TE event rate in patients with TE prior to the trials was also reduced by 89% (P=<0.001).

Most TE events prior to eculizumab treatment occurred in patients receiving antithrombotics, either therapeutically or prophylactically. This indicates that the therapy may be insufficient to prevent thrombosis.

Pre-eculizumab treatment, 195 patients experienced 124 TE events. Of the 195 patients, 103 were on antithrombotics.

Of the 103 patients on antithrombotics, there were 54 TE events in 30 patients pre-eculizumab, compared to 1 TE event during eculizumab treatment. This demonstrates that eculizumab significantly reduces the risk of thrombosis in PNH patients, despite treatment with antithrombotics (P=<0.001).

Pre-eculizumab, TE was frequent in patients with lower levels of hemolysis and with mild anemia. Eculizumab significantly reduced TE across these and other subgroups (P=<0.001).

Dr Hillman said these data demonstrate the efficacy of long-term eculizumab treatment in its ability to significantly reduce the occurrence of thrombosis in PNH patients. Because TE accounts for the majority of deaths in PNH, it is reasonable to expect that eculizumab treatment, by decreasing the risk of TE, will increase the life-expectancy in PNH.

PNH is a rare, acquired, and potentially life-threatening disease of the blood characterized by hemolytic anemia, thrombosis, and red-colored urine, resulting from the breakdown of red blood cells.

TE is one of the most feared complications associated with PNH and accounts for approximately 45% of PNH patient deaths. The disease can occur even in individuals who have no previous history of thrombosis.

Patients with PNH are usually treated with anticoagulants on a prophylactic basis. However, these anticoagulants increase the risk of life-threatening hemorrhage without eliminating the potential for thrombosis, which can occur in as many as 30% of the patients who receive anticoagulant treatment. 

VIENNA—Long-term treatment with eculizumab, a recombinant humanized monoclonal antibody, significantly reduces the risk of thrombosis in patients with paroxysmal nocturnal hemoglobinuria (PNH), according to the results of a recent multicenter study.

Peter Hillmen, MD, of the Leeds Teaching Hospitals NHS Trust, reported the results of the study at the 12th Congress of the European Hematology Association in June 2007.

Dr Hillmen and colleagues prospectively examined the aggregate thromboembolism (TE) event rate in eculizumab-treated patients from 3 recent parent studies, as well as a subsequent common extension study. They compared those rates to the TE rate in the same patients’ pre-eculizumab treatment.

Eculizumab, which is designed to inhibit activation of terminal complement components that have been implicated in the development of PNH, reduced the TE rate in each of the three parent studies.

Most importantly, the aggregate TE event rate during eculizumab treatment was significantly reduced by 85% (P=<0.001), when compared with the same patients before eculizumab treatment.

With restriction of the pretreatment observation period to the 12 months immediately preceding eculizumab treatment, the TE event rate during treatment was reduced by 94% (P=0.002). The TE event rate in patients with TE prior to the trials was also reduced by 89% (P=<0.001).

Most TE events prior to eculizumab treatment occurred in patients receiving antithrombotics, either therapeutically or prophylactically. This indicates that the therapy may be insufficient to prevent thrombosis.

Pre-eculizumab treatment, 195 patients experienced 124 TE events. Of the 195 patients, 103 were on antithrombotics.

Of the 103 patients on antithrombotics, there were 54 TE events in 30 patients pre-eculizumab, compared to 1 TE event during eculizumab treatment. This demonstrates that eculizumab significantly reduces the risk of thrombosis in PNH patients, despite treatment with antithrombotics (P=<0.001).

Pre-eculizumab, TE was frequent in patients with lower levels of hemolysis and with mild anemia. Eculizumab significantly reduced TE across these and other subgroups (P=<0.001).

Dr Hillman said these data demonstrate the efficacy of long-term eculizumab treatment in its ability to significantly reduce the occurrence of thrombosis in PNH patients. Because TE accounts for the majority of deaths in PNH, it is reasonable to expect that eculizumab treatment, by decreasing the risk of TE, will increase the life-expectancy in PNH.

PNH is a rare, acquired, and potentially life-threatening disease of the blood characterized by hemolytic anemia, thrombosis, and red-colored urine, resulting from the breakdown of red blood cells.

TE is one of the most feared complications associated with PNH and accounts for approximately 45% of PNH patient deaths. The disease can occur even in individuals who have no previous history of thrombosis.

Patients with PNH are usually treated with anticoagulants on a prophylactic basis. However, these anticoagulants increase the risk of life-threatening hemorrhage without eliminating the potential for thrombosis, which can occur in as many as 30% of the patients who receive anticoagulant treatment. 

VIENNA—Long-term treatment with eculizumab, a recombinant humanized monoclonal antibody, significantly reduces the risk of thrombosis in patients with paroxysmal nocturnal hemoglobinuria (PNH), according to the results of a recent multicenter study.

Peter Hillmen, MD, of the Leeds Teaching Hospitals NHS Trust, reported the results of the study at the 12th Congress of the European Hematology Association in June 2007.

Dr Hillmen and colleagues prospectively examined the aggregate thromboembolism (TE) event rate in eculizumab-treated patients from 3 recent parent studies, as well as a subsequent common extension study. They compared those rates to the TE rate in the same patients’ pre-eculizumab treatment.

Eculizumab, which is designed to inhibit activation of terminal complement components that have been implicated in the development of PNH, reduced the TE rate in each of the three parent studies.

Most importantly, the aggregate TE event rate during eculizumab treatment was significantly reduced by 85% (P=<0.001), when compared with the same patients before eculizumab treatment.

With restriction of the pretreatment observation period to the 12 months immediately preceding eculizumab treatment, the TE event rate during treatment was reduced by 94% (P=0.002). The TE event rate in patients with TE prior to the trials was also reduced by 89% (P=<0.001).

Most TE events prior to eculizumab treatment occurred in patients receiving antithrombotics, either therapeutically or prophylactically. This indicates that the therapy may be insufficient to prevent thrombosis.

Pre-eculizumab treatment, 195 patients experienced 124 TE events. Of the 195 patients, 103 were on antithrombotics.

Of the 103 patients on antithrombotics, there were 54 TE events in 30 patients pre-eculizumab, compared to 1 TE event during eculizumab treatment. This demonstrates that eculizumab significantly reduces the risk of thrombosis in PNH patients, despite treatment with antithrombotics (P=<0.001).

Pre-eculizumab, TE was frequent in patients with lower levels of hemolysis and with mild anemia. Eculizumab significantly reduced TE across these and other subgroups (P=<0.001).

Dr Hillman said these data demonstrate the efficacy of long-term eculizumab treatment in its ability to significantly reduce the occurrence of thrombosis in PNH patients. Because TE accounts for the majority of deaths in PNH, it is reasonable to expect that eculizumab treatment, by decreasing the risk of TE, will increase the life-expectancy in PNH.

PNH is a rare, acquired, and potentially life-threatening disease of the blood characterized by hemolytic anemia, thrombosis, and red-colored urine, resulting from the breakdown of red blood cells.

TE is one of the most feared complications associated with PNH and accounts for approximately 45% of PNH patient deaths. The disease can occur even in individuals who have no previous history of thrombosis.

Patients with PNH are usually treated with anticoagulants on a prophylactic basis. However, these anticoagulants increase the risk of life-threatening hemorrhage without eliminating the potential for thrombosis, which can occur in as many as 30% of the patients who receive anticoagulant treatment. 

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

 

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

 

 

---

 

 

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

 

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

 

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

 

 

---

 

 

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

 

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

 

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

 

 

---

 

 

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

 

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

 

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

 

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

 

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.