The Institute of Medicine reports To Err is Human and Crossing the Quality Chasm have drawn great attention to quality improvement and patient safety in the hospital setting.13 With the growth of the hospitalist field over the past several years,4 there has been increasing discussion about the importance of assuring quality of care, and some have argued that improving health care quality and reducing avoidable errors may be among the hospitalist's most important functions.5 Most discussions about the quality of hospital care have concerned the inpatient stay itself. However, the growth of hospital medicine, with its inherent discontinuity between inpatient and outpatient physicians, has intensified interest in the transition period from hospital discharge until first outpatient appointment.

At discharge, physicians may prescribe medications, order home health services, and arrange follow‐up appointments. It is often assumed a patient will remain stable after discharge and will follow up at the outpatient physician's office. Previous research has shown there may be problems with these assumptions. A patient may not understand the postdischarge treatment plan as well as the physician thinks.6 A recent study found that adverse events after discharge were common and often preventable.7 A follow‐up study confirmed that approximately 25% of patients had an adverse event after hospital discharge and that most adverse events caused symptoms but did not result in an emergency department visit, hospitalization, or death.8 Another study also found the prevalence of medical errors following hospitalization was high because of the discontinuity of care from the inpatient to the outpatient setting.9 These errors resulted in an increased rate of rehospitalization.

Telephone follow‐up may be a useful method of bridging the gap in care between discharge and the first outpatient appointment.10, 11 In most previous studies it was 2 or 3 weeks after discharge before patients were contacted or their records studied. By this point, patients who had done poorly may already have been readmitted or sought care at alternative locations. In one small study, pharmacists found that 12 of 79 patients (15%) contacted by telephone within 2 days of discharge12 had symptoms there were new or had worsened since discharge. The purpose of the present investigation was to extend these previous findings through a large multicenter study of how frequently patients had new or worsened symptoms within several days of discharge.

METHODS

RESULTS

During the study period, 48,236 patients were discharged to their homes from an acute care hospital. The IPC call center successfully contacted 16,135 patients after discharge, of whom 368 patients (2.3%) were excluded because of incomplete answers, leaving 15,767 as the valid study population (effective response rate = 32.4%). Of these, 98.9% were contacted within the first 5 days. The primary reasons for nonresponse or noninclusion in the present analysis were no answer after 2 attempts (52%) and missing or incorrect phone numbers (16%). If there was an answering machine, a message was left for the patient to call back. Those who called back accounted for fewer than 1% of all the patients.

A comparison of participants versus nonparticipants is shown in Table 1. The mean age of surveyed patients was 60.1 years, and 57% were female. The most common categories of insurance coverage were Medicare and HMO. The inpatient severity of illness of most patients was minor to moderate. Self‐reported health status was normally distributed, with the greatest percentage of patients rating their health as fair or good. On average, nonparticipants were younger than participants, more likely to be male, had a different pattern of health insurance, and a slightly lower severity of illness. The top 10 DRGs were the same for the respondents and nonrespondents, and the order of these 10 diagnoses was very similar.

Of the 15,767 patients contacted, 11.9% (N = 1876) reported symptoms that were new or had worsened since leaving the hospital. Sixty‐four percent of these patients had new symptoms, and 36% had worsening symptoms. These two groups were combined for analysis in this study because for both groups, identification and action are important. Of the patients with new or worse symptoms, 37% required no assistance from the nurse because they had already notified a doctor and/or were doing something about it. The other 63% either had not notified their doctor or had concerns about their signs and symptoms. The most common action taken by the nurse was patient education regarding the symptoms. Of those requiring nurse intervention in addition to education, the most common intervention was to contact the patient's primary care provider or specialist about the patient's symptoms, followed by contacting the hospitalist. In 72% of nurse interventions, the patient's primary care physician or a specialist was contacted about the new or worsened symptoms. Other interventions included contacting the physician's office to obtain a prescription for a medication for the symptom, to get an appointment for the patient, or to reschedule an appointment to be earlier. A referral to an emergency room or urgent care center was given to 4% of patients.

Mean age of the patients with new or worsened symptoms was 60.5 years. The age distribution of symptomatic and asymptomatic patients was not significantly different, whether comparing by mean, median, or decades. Table 2 illustrates factors associated with the increased rate of new or worsened symptoms. Women were more likely than men to report symptoms (13.0% vs. 10.3%, P < .0001). As health status worsened, the percentage of patients with new or worsened symptoms increased (P < .0001), as it did with increased inpatient SOI (P < .0001). There was no correlation between self‐rated health status and SOI score based on DRG score, suggesting they measured different parameters. Table 3 lists the percentages of patients reporting new or worsened symptoms for the most common DRGs. The only significant distinction was that patients discharged with a DRG of chest pain were less likely to report symptoms than were all patients.

The symptoms the patients reported are categorized in Table 4 without distinction as to whether they are primary or secondary. Gastrointestinal symptoms were the most common category of symptoms, followed by general symptoms, cardiovascular symptoms, and pain. The most common symptoms reported were fatigue/weakness, nausea/vomiting, and edema.

The call center assessed whether the patient had difficulty making a follow‐up appointment and whether an appointment was scheduled within 2 weeks of discharge. Patients with new or worsening symptoms were only minimally more likely to have scheduled follow‐up (61.0% vs. 58.4% for patients not reporting new or worsening symptoms, P < .05). Symptomatic patients had a higher prevalence of medication issues, defined as not picking up their prescriptions or not understanding how to take their medication (22.2% vs. 6.8% for asymptomatic patients; P < .0001). Likewise, the prevalence of symptomatic patients having problems receiving scheduled home health care services was 5.8%, compared with a prevalence of 3.6% for asymptomatic patients (P < .0001).

DISCUSSION

Enhancing the quality of care provided by hospitalists means not only improving care during hospitalization but also assuring patient stability between discharge and outpatient follow‐up. As part of efforts to improve transition management, the call center at IPC attempted to contact all patients discharged home within several days of discharge. Of 15,767 patients surveyed between May 1, 2003, and October 31, 2003, 11.9% (N = 1876) had new or worsening symptoms since leaving the hospital only 2 or 3 days earlier. We had hypothesized that older patients might be more symptomatic than younger ones, but found no difference in the prevalence of new or worsening symptoms based on age. Women were more likely to be symptomatic than men.

We defined appropriate postdischarge follow‐up as having an appointment with an outpatient physician within 2 weeks. A previous study of psychiatric patients documented that keeping a follow‐up appointment significantly reduces the risk of rehospitalization.17 Similar data do not exist for medical patients. Our data demonstrated that symptomatic patients were only minimally more likely to have made a follow‐up appointment with their outpatient physician within the first 2 weeks than were those patients who were not symptomatic. As part of patient education at discharge, clinicians routinely counsel patients to call their outpatient physician should they experience new or worsening symptoms once at home. Inpatient physicians may assume this recommendation provides a safety net for the patients should they develop problems after discharge. However, our finding that almost 40% of patients with new or worsening symptoms within 2‐3 days of discharge had not made a follow‐up appointment with their physician suggests many patients fall through this safety net. Although there was a slight statistically significant difference between the groups, this difference was not clinically significant. One potential limitation of our data is that we did not examine whether there was a correlation between the day of the week that a patient was discharged and inability to make a follow‐up appointment.

As part of the survey script (see Appendix), we inquired whether patients were able to pick up their prescriptions and whether they understood how to take their medication. A high percentage of patients in our study reported having one of these medication issues in the first several days following hospital discharge, providing an opportunity for early intervention and prevention of medical error. Forster and others have demonstrated that adverse events and medical errors are common in the postdischarge period, affecting 23%‐49% of patients.79 Errors in the transition from inpatient to outpatient care increased the 3‐month rate of rehospitalization.9 New or worsening symptoms represented the most common adverse event.8 Noting that many of these postdischarge complications could be preventable if detected early, Forster suggested system changes such as earlier follow‐up with the outpatient physician or a postdischarge telephone call to check on the patient's status.7, 18 Future studies are planned to further analyze our data on medication issues and to determine if these problems are more prevalent for certain medications or diagnoses.

Comprehensive discharge planning remains an essential step in the discharge process. This may involve prescribing medications, arranging home health care services, and arranging outpatient follow‐up. The traditional hospital discharge process does not adequately ensure that patients understand their discharge plan and are able to comply with it. Calkins et al. compared physicians' perceptions of patients' understanding of medication side effects and activity restrictions with patients' actual understanding.6 They found that, compared with what was reported by patients, physicians overestimated the time spent discussing discharge plans and how well patients understood medication side effects and activity restrictions.

An important method for reducing patient problems is to contact patients by telephone after discharge in order to identify any health care issues. Previous research has confirmed that follow‐up telephone calls improve health outcomes and decrease resource utilization of patients, mainly those discharged from the emergency department.10, 11, 1923 A study of telephone follow‐up after ambulatory care visits did not find significant benefits of this procedure.24 In one of the few studies of telephone calls after hospitalization, pharmacists contacted patients 2 days after discharge and were able to detect and resolve medication‐related problems in 19% of patients and learned of new or worsening symptoms in 15%. Patient satisfaction was improved, and the intervention resulted in a lower rate of repeat visits to the emergency room within 30 days of discharge.12 Another study of telephone follow‐up following hospital discharge compared proactively calling all patients with providing a phone number that patients can call if they have questions. The study demonstrated that very few patients called the number provided, but of those patients called by the nursing service, more than 90% had questions about self‐care and recovery.25 These findings demonstrate the value of proactively contacting patients in the first several days after discharge, when problems can be detected and interventions initiated earlier.

One potential concern with this study was the low response rate. This was a retrospective analysis of an existing discharge management call‐center system, not a prospective study. We were not able to reach 52% of the patients discharged after 2 attempts by telephone. To have our call center make additional attempts to reach each patient by telephone would require a significant increase in the size of the call center, because at the time of the study, the staff was handling more than 370 patients discharged home a day. The telephone number of 16% of patients was missing or incorrect. We have since developed internal quality improvement mechanisms to decrease this percentage. After subtracting the patients we were unable to reach and those whose phone number was missing or incorrect, we were able to contact 32.4% of all the patients discharged home.

Several reasons explain the response rate found by many prospective research studies. In most studies of telephone follow‐up, patients must be able to consent to participate in order to be considered eligible inclusion. This raises the response rate because patients who do not consent to participate, have language barriers, or have no telephone are excluded from the study. In our study none of these types of patients were excluded. There are 2 additional differences between our study and many published studies that involve telephone surveys. Ours was not a prospective research study, and we contacted many more patients than did other studies. For example, a study by Forster et al. involved only 581 patients, and the research staff was diligent in its efforts to reach the patients,7 making up to 20 attempts for each patient. They reported a response rate of 69%. If they had included patients who were non‐English speakers or had no phone in their study, the response rate would have been 59%. Shesser et al. were able to reach 144 of 297 patients in their study of emergency room follow‐up, for a 48.4% response rate.25 The response rate in a study of telephone consultation with asthma patients was quite similar to ours. They enrolled 932 eligible patients, of whom they were able to reach 278, for a response rate of 30%.

It is possible that the rate of symptoms and the other variables we measured relative to this would have been different if we had been able to reach 100% of patients. There were some demographic differences between the patients we were able to reach and those we were not (Table 1). The nonresponders were slightly younger and slightly more likely to be female. Nonresponders were more likely to have Medicaid or commercial insurance or be self‐pay and were less likely to have Medicare. In addition, nonresponders had less severe illness. Although this scenario is highly unlikely, if none of the nonresponders had new or worsening symptoms, the rate of symptoms would only have been 3.86%. Conversely, it is possible but also very unlikely that a greater percentage of the nonresponders had new or worsening symptoms. Given the demographics of our study participants, we would expect a potentially slightly lower rate of signs and symptoms.

The present study had several other limitations. First, all patients surveyed were cared for by IPC‐employed physicians. It is possible that reported rates of symptoms and other postdischarge issues are not generalizable to other hospitalist practices. However, the present data were collected at more than 100 health care facilities in 10 health care markets, and the patients were cared for by more than 200 physicians. Therefore, it is unlikely these results would have been significantly influenced by a particular physician's or institution's practice patterns.

Second, because of the large number of facilities involved and that we could only track readmissions to facilities where our own hospitalists practice, we were not able to report 30‐ or 90‐day readmission rates or emergency room visit rates. In a prospective study, these would be important variables to track in order to assess the clinical relevance of the symptoms. We could track this data for some institutions, but for most of them, the quality of data was not sufficient to be meaningful or to make conclusions.

An additional limitation is that the call center did not differentiate between clinically minor and major symptoms. The inclusion of symptoms perhaps considered minor might have elevated the reported symptom frequency. However, the definitions of minor and major symptoms are very subjective, and a clinician's definitions might differ from those of a patient who is at home and uncomfortable. For example, nausea or loss of appetite related to new medications may be considered minor clinically but could be devastating to the patient experiencing them, leading the patient to stop taking the medication. Conversely, symptoms that may be considered nonsignificant by the patient may be interpreted as indicating clinically significant disease by a physician. Therefore, we would argue that, regardless of the severity of the symptom, follow‐up with a clinician is important.

Another limitation is based on our definition of an adequate follow‐up appointment as one scheduled within 2 weeks of discharge. It might be argued that if a patient's new symptoms were considered minor clinically, then a follow‐up interval greater than 2 weeks might be considered adequate. However, as already noted, a patient's criteria for considering a symptom minor and not requiring follow‐up may differ from a clinician's criteria. Also, the standardized discharge process requires that the hospitalist identify a physician for outpatient follow‐up and specify the period when the patient is to see the physician. Because of the inherent variability in having a many hospitalists practicing in many hospitals, not all patients had a scheduled appointment at discharge. We were not able to determine whether patients had an appointment date and time for follow‐up before discharge or had only received instructions to call the office for an appointment.

The Institute of Medicine, in its report Crossing the Quality Chasm, identified the coordination of care across services and sites of care as one of the health care system's redesign imperatives.2 Hospitalists are in a unique position to address transition care issues. Managing the transition from inpatient to outpatient care is vitally important, and hospitalists should play an essential role in designing a transition management system for discharged patients. Although individual efforts by hospitalists are essential to assuring postdischarge contact with patients, there is increasing agreement that system solutions are needed to improve the quality of care in the transition period following hospitalization. Improving a health care process involves more than working harder; it involves working differently.3 It is therefore imperative that hospitalist programs develop effective systems to manage the transition period until safe arrival by the patient in the outpatient physician's office.

In summary, 11.9% of patients contacted by a telephone call center within several days of discharge had new or worsening symptoms since discharge. There was no difference by age in the prevalence of symptoms. Patients who rated their health status as fair to poor were more likely to be symptomatic. Symptomatic patients were also more likely to have difficulty obtaining or understanding how to take their medications and receiving home health services. Patients who felt poorly were only minimally more likely to have made an appointment for follow‐up with their outpatient physician. It is hoped that by identifying patients who are doing poorly after discharge and intervening as necessary, we can improve the health outcome of our patients, as well as reduce the number of emergency room visits and readmission rates. Although actions by individual physicians are important, a system to manage the postdischarge transition period is essential for improving posthospitalization outcomes.

The Institute of Medicine reports To Err is Human and Crossing the Quality Chasm have drawn great attention to quality improvement and patient safety in the hospital setting.13 With the growth of the hospitalist field over the past several years,4 there has been increasing discussion about the importance of assuring quality of care, and some have argued that improving health care quality and reducing avoidable errors may be among the hospitalist's most important functions.5 Most discussions about the quality of hospital care have concerned the inpatient stay itself. However, the growth of hospital medicine, with its inherent discontinuity between inpatient and outpatient physicians, has intensified interest in the transition period from hospital discharge until first outpatient appointment.

At discharge, physicians may prescribe medications, order home health services, and arrange follow‐up appointments. It is often assumed a patient will remain stable after discharge and will follow up at the outpatient physician's office. Previous research has shown there may be problems with these assumptions. A patient may not understand the postdischarge treatment plan as well as the physician thinks.6 A recent study found that adverse events after discharge were common and often preventable.7 A follow‐up study confirmed that approximately 25% of patients had an adverse event after hospital discharge and that most adverse events caused symptoms but did not result in an emergency department visit, hospitalization, or death.8 Another study also found the prevalence of medical errors following hospitalization was high because of the discontinuity of care from the inpatient to the outpatient setting.9 These errors resulted in an increased rate of rehospitalization.

Telephone follow‐up may be a useful method of bridging the gap in care between discharge and the first outpatient appointment.10, 11 In most previous studies it was 2 or 3 weeks after discharge before patients were contacted or their records studied. By this point, patients who had done poorly may already have been readmitted or sought care at alternative locations. In one small study, pharmacists found that 12 of 79 patients (15%) contacted by telephone within 2 days of discharge12 had symptoms there were new or had worsened since discharge. The purpose of the present investigation was to extend these previous findings through a large multicenter study of how frequently patients had new or worsened symptoms within several days of discharge.

METHODS

RESULTS

During the study period, 48,236 patients were discharged to their homes from an acute care hospital. The IPC call center successfully contacted 16,135 patients after discharge, of whom 368 patients (2.3%) were excluded because of incomplete answers, leaving 15,767 as the valid study population (effective response rate = 32.4%). Of these, 98.9% were contacted within the first 5 days. The primary reasons for nonresponse or noninclusion in the present analysis were no answer after 2 attempts (52%) and missing or incorrect phone numbers (16%). If there was an answering machine, a message was left for the patient to call back. Those who called back accounted for fewer than 1% of all the patients.

A comparison of participants versus nonparticipants is shown in Table 1. The mean age of surveyed patients was 60.1 years, and 57% were female. The most common categories of insurance coverage were Medicare and HMO. The inpatient severity of illness of most patients was minor to moderate. Self‐reported health status was normally distributed, with the greatest percentage of patients rating their health as fair or good. On average, nonparticipants were younger than participants, more likely to be male, had a different pattern of health insurance, and a slightly lower severity of illness. The top 10 DRGs were the same for the respondents and nonrespondents, and the order of these 10 diagnoses was very similar.

Of the 15,767 patients contacted, 11.9% (N = 1876) reported symptoms that were new or had worsened since leaving the hospital. Sixty‐four percent of these patients had new symptoms, and 36% had worsening symptoms. These two groups were combined for analysis in this study because for both groups, identification and action are important. Of the patients with new or worse symptoms, 37% required no assistance from the nurse because they had already notified a doctor and/or were doing something about it. The other 63% either had not notified their doctor or had concerns about their signs and symptoms. The most common action taken by the nurse was patient education regarding the symptoms. Of those requiring nurse intervention in addition to education, the most common intervention was to contact the patient's primary care provider or specialist about the patient's symptoms, followed by contacting the hospitalist. In 72% of nurse interventions, the patient's primary care physician or a specialist was contacted about the new or worsened symptoms. Other interventions included contacting the physician's office to obtain a prescription for a medication for the symptom, to get an appointment for the patient, or to reschedule an appointment to be earlier. A referral to an emergency room or urgent care center was given to 4% of patients.

Mean age of the patients with new or worsened symptoms was 60.5 years. The age distribution of symptomatic and asymptomatic patients was not significantly different, whether comparing by mean, median, or decades. Table 2 illustrates factors associated with the increased rate of new or worsened symptoms. Women were more likely than men to report symptoms (13.0% vs. 10.3%, P < .0001). As health status worsened, the percentage of patients with new or worsened symptoms increased (P < .0001), as it did with increased inpatient SOI (P < .0001). There was no correlation between self‐rated health status and SOI score based on DRG score, suggesting they measured different parameters. Table 3 lists the percentages of patients reporting new or worsened symptoms for the most common DRGs. The only significant distinction was that patients discharged with a DRG of chest pain were less likely to report symptoms than were all patients.

The symptoms the patients reported are categorized in Table 4 without distinction as to whether they are primary or secondary. Gastrointestinal symptoms were the most common category of symptoms, followed by general symptoms, cardiovascular symptoms, and pain. The most common symptoms reported were fatigue/weakness, nausea/vomiting, and edema.

The call center assessed whether the patient had difficulty making a follow‐up appointment and whether an appointment was scheduled within 2 weeks of discharge. Patients with new or worsening symptoms were only minimally more likely to have scheduled follow‐up (61.0% vs. 58.4% for patients not reporting new or worsening symptoms, P < .05). Symptomatic patients had a higher prevalence of medication issues, defined as not picking up their prescriptions or not understanding how to take their medication (22.2% vs. 6.8% for asymptomatic patients; P < .0001). Likewise, the prevalence of symptomatic patients having problems receiving scheduled home health care services was 5.8%, compared with a prevalence of 3.6% for asymptomatic patients (P < .0001).

DISCUSSION

Enhancing the quality of care provided by hospitalists means not only improving care during hospitalization but also assuring patient stability between discharge and outpatient follow‐up. As part of efforts to improve transition management, the call center at IPC attempted to contact all patients discharged home within several days of discharge. Of 15,767 patients surveyed between May 1, 2003, and October 31, 2003, 11.9% (N = 1876) had new or worsening symptoms since leaving the hospital only 2 or 3 days earlier. We had hypothesized that older patients might be more symptomatic than younger ones, but found no difference in the prevalence of new or worsening symptoms based on age. Women were more likely to be symptomatic than men.

We defined appropriate postdischarge follow‐up as having an appointment with an outpatient physician within 2 weeks. A previous study of psychiatric patients documented that keeping a follow‐up appointment significantly reduces the risk of rehospitalization.17 Similar data do not exist for medical patients. Our data demonstrated that symptomatic patients were only minimally more likely to have made a follow‐up appointment with their outpatient physician within the first 2 weeks than were those patients who were not symptomatic. As part of patient education at discharge, clinicians routinely counsel patients to call their outpatient physician should they experience new or worsening symptoms once at home. Inpatient physicians may assume this recommendation provides a safety net for the patients should they develop problems after discharge. However, our finding that almost 40% of patients with new or worsening symptoms within 2‐3 days of discharge had not made a follow‐up appointment with their physician suggests many patients fall through this safety net. Although there was a slight statistically significant difference between the groups, this difference was not clinically significant. One potential limitation of our data is that we did not examine whether there was a correlation between the day of the week that a patient was discharged and inability to make a follow‐up appointment.

As part of the survey script (see Appendix), we inquired whether patients were able to pick up their prescriptions and whether they understood how to take their medication. A high percentage of patients in our study reported having one of these medication issues in the first several days following hospital discharge, providing an opportunity for early intervention and prevention of medical error. Forster and others have demonstrated that adverse events and medical errors are common in the postdischarge period, affecting 23%‐49% of patients.79 Errors in the transition from inpatient to outpatient care increased the 3‐month rate of rehospitalization.9 New or worsening symptoms represented the most common adverse event.8 Noting that many of these postdischarge complications could be preventable if detected early, Forster suggested system changes such as earlier follow‐up with the outpatient physician or a postdischarge telephone call to check on the patient's status.7, 18 Future studies are planned to further analyze our data on medication issues and to determine if these problems are more prevalent for certain medications or diagnoses.

Comprehensive discharge planning remains an essential step in the discharge process. This may involve prescribing medications, arranging home health care services, and arranging outpatient follow‐up. The traditional hospital discharge process does not adequately ensure that patients understand their discharge plan and are able to comply with it. Calkins et al. compared physicians' perceptions of patients' understanding of medication side effects and activity restrictions with patients' actual understanding.6 They found that, compared with what was reported by patients, physicians overestimated the time spent discussing discharge plans and how well patients understood medication side effects and activity restrictions.

An important method for reducing patient problems is to contact patients by telephone after discharge in order to identify any health care issues. Previous research has confirmed that follow‐up telephone calls improve health outcomes and decrease resource utilization of patients, mainly those discharged from the emergency department.10, 11, 1923 A study of telephone follow‐up after ambulatory care visits did not find significant benefits of this procedure.24 In one of the few studies of telephone calls after hospitalization, pharmacists contacted patients 2 days after discharge and were able to detect and resolve medication‐related problems in 19% of patients and learned of new or worsening symptoms in 15%. Patient satisfaction was improved, and the intervention resulted in a lower rate of repeat visits to the emergency room within 30 days of discharge.12 Another study of telephone follow‐up following hospital discharge compared proactively calling all patients with providing a phone number that patients can call if they have questions. The study demonstrated that very few patients called the number provided, but of those patients called by the nursing service, more than 90% had questions about self‐care and recovery.25 These findings demonstrate the value of proactively contacting patients in the first several days after discharge, when problems can be detected and interventions initiated earlier.

One potential concern with this study was the low response rate. This was a retrospective analysis of an existing discharge management call‐center system, not a prospective study. We were not able to reach 52% of the patients discharged after 2 attempts by telephone. To have our call center make additional attempts to reach each patient by telephone would require a significant increase in the size of the call center, because at the time of the study, the staff was handling more than 370 patients discharged home a day. The telephone number of 16% of patients was missing or incorrect. We have since developed internal quality improvement mechanisms to decrease this percentage. After subtracting the patients we were unable to reach and those whose phone number was missing or incorrect, we were able to contact 32.4% of all the patients discharged home.

Several reasons explain the response rate found by many prospective research studies. In most studies of telephone follow‐up, patients must be able to consent to participate in order to be considered eligible inclusion. This raises the response rate because patients who do not consent to participate, have language barriers, or have no telephone are excluded from the study. In our study none of these types of patients were excluded. There are 2 additional differences between our study and many published studies that involve telephone surveys. Ours was not a prospective research study, and we contacted many more patients than did other studies. For example, a study by Forster et al. involved only 581 patients, and the research staff was diligent in its efforts to reach the patients,7 making up to 20 attempts for each patient. They reported a response rate of 69%. If they had included patients who were non‐English speakers or had no phone in their study, the response rate would have been 59%. Shesser et al. were able to reach 144 of 297 patients in their study of emergency room follow‐up, for a 48.4% response rate.25 The response rate in a study of telephone consultation with asthma patients was quite similar to ours. They enrolled 932 eligible patients, of whom they were able to reach 278, for a response rate of 30%.

It is possible that the rate of symptoms and the other variables we measured relative to this would have been different if we had been able to reach 100% of patients. There were some demographic differences between the patients we were able to reach and those we were not (Table 1). The nonresponders were slightly younger and slightly more likely to be female. Nonresponders were more likely to have Medicaid or commercial insurance or be self‐pay and were less likely to have Medicare. In addition, nonresponders had less severe illness. Although this scenario is highly unlikely, if none of the nonresponders had new or worsening symptoms, the rate of symptoms would only have been 3.86%. Conversely, it is possible but also very unlikely that a greater percentage of the nonresponders had new or worsening symptoms. Given the demographics of our study participants, we would expect a potentially slightly lower rate of signs and symptoms.

The present study had several other limitations. First, all patients surveyed were cared for by IPC‐employed physicians. It is possible that reported rates of symptoms and other postdischarge issues are not generalizable to other hospitalist practices. However, the present data were collected at more than 100 health care facilities in 10 health care markets, and the patients were cared for by more than 200 physicians. Therefore, it is unlikely these results would have been significantly influenced by a particular physician's or institution's practice patterns.

Second, because of the large number of facilities involved and that we could only track readmissions to facilities where our own hospitalists practice, we were not able to report 30‐ or 90‐day readmission rates or emergency room visit rates. In a prospective study, these would be important variables to track in order to assess the clinical relevance of the symptoms. We could track this data for some institutions, but for most of them, the quality of data was not sufficient to be meaningful or to make conclusions.

An additional limitation is that the call center did not differentiate between clinically minor and major symptoms. The inclusion of symptoms perhaps considered minor might have elevated the reported symptom frequency. However, the definitions of minor and major symptoms are very subjective, and a clinician's definitions might differ from those of a patient who is at home and uncomfortable. For example, nausea or loss of appetite related to new medications may be considered minor clinically but could be devastating to the patient experiencing them, leading the patient to stop taking the medication. Conversely, symptoms that may be considered nonsignificant by the patient may be interpreted as indicating clinically significant disease by a physician. Therefore, we would argue that, regardless of the severity of the symptom, follow‐up with a clinician is important.

Another limitation is based on our definition of an adequate follow‐up appointment as one scheduled within 2 weeks of discharge. It might be argued that if a patient's new symptoms were considered minor clinically, then a follow‐up interval greater than 2 weeks might be considered adequate. However, as already noted, a patient's criteria for considering a symptom minor and not requiring follow‐up may differ from a clinician's criteria. Also, the standardized discharge process requires that the hospitalist identify a physician for outpatient follow‐up and specify the period when the patient is to see the physician. Because of the inherent variability in having a many hospitalists practicing in many hospitals, not all patients had a scheduled appointment at discharge. We were not able to determine whether patients had an appointment date and time for follow‐up before discharge or had only received instructions to call the office for an appointment.

The Institute of Medicine, in its report Crossing the Quality Chasm, identified the coordination of care across services and sites of care as one of the health care system's redesign imperatives.2 Hospitalists are in a unique position to address transition care issues. Managing the transition from inpatient to outpatient care is vitally important, and hospitalists should play an essential role in designing a transition management system for discharged patients. Although individual efforts by hospitalists are essential to assuring postdischarge contact with patients, there is increasing agreement that system solutions are needed to improve the quality of care in the transition period following hospitalization. Improving a health care process involves more than working harder; it involves working differently.3 It is therefore imperative that hospitalist programs develop effective systems to manage the transition period until safe arrival by the patient in the outpatient physician's office.

In summary, 11.9% of patients contacted by a telephone call center within several days of discharge had new or worsening symptoms since discharge. There was no difference by age in the prevalence of symptoms. Patients who rated their health status as fair to poor were more likely to be symptomatic. Symptomatic patients were also more likely to have difficulty obtaining or understanding how to take their medications and receiving home health services. Patients who felt poorly were only minimally more likely to have made an appointment for follow‐up with their outpatient physician. It is hoped that by identifying patients who are doing poorly after discharge and intervening as necessary, we can improve the health outcome of our patients, as well as reduce the number of emergency room visits and readmission rates. Although actions by individual physicians are important, a system to manage the postdischarge transition period is essential for improving posthospitalization outcomes.

The Institute of Medicine reports To Err is Human and Crossing the Quality Chasm have drawn great attention to quality improvement and patient safety in the hospital setting.13 With the growth of the hospitalist field over the past several years,4 there has been increasing discussion about the importance of assuring quality of care, and some have argued that improving health care quality and reducing avoidable errors may be among the hospitalist's most important functions.5 Most discussions about the quality of hospital care have concerned the inpatient stay itself. However, the growth of hospital medicine, with its inherent discontinuity between inpatient and outpatient physicians, has intensified interest in the transition period from hospital discharge until first outpatient appointment.

At discharge, physicians may prescribe medications, order home health services, and arrange follow‐up appointments. It is often assumed a patient will remain stable after discharge and will follow up at the outpatient physician's office. Previous research has shown there may be problems with these assumptions. A patient may not understand the postdischarge treatment plan as well as the physician thinks.6 A recent study found that adverse events after discharge were common and often preventable.7 A follow‐up study confirmed that approximately 25% of patients had an adverse event after hospital discharge and that most adverse events caused symptoms but did not result in an emergency department visit, hospitalization, or death.8 Another study also found the prevalence of medical errors following hospitalization was high because of the discontinuity of care from the inpatient to the outpatient setting.9 These errors resulted in an increased rate of rehospitalization.

Telephone follow‐up may be a useful method of bridging the gap in care between discharge and the first outpatient appointment.10, 11 In most previous studies it was 2 or 3 weeks after discharge before patients were contacted or their records studied. By this point, patients who had done poorly may already have been readmitted or sought care at alternative locations. In one small study, pharmacists found that 12 of 79 patients (15%) contacted by telephone within 2 days of discharge12 had symptoms there were new or had worsened since discharge. The purpose of the present investigation was to extend these previous findings through a large multicenter study of how frequently patients had new or worsened symptoms within several days of discharge.

METHODS

RESULTS

During the study period, 48,236 patients were discharged to their homes from an acute care hospital. The IPC call center successfully contacted 16,135 patients after discharge, of whom 368 patients (2.3%) were excluded because of incomplete answers, leaving 15,767 as the valid study population (effective response rate = 32.4%). Of these, 98.9% were contacted within the first 5 days. The primary reasons for nonresponse or noninclusion in the present analysis were no answer after 2 attempts (52%) and missing or incorrect phone numbers (16%). If there was an answering machine, a message was left for the patient to call back. Those who called back accounted for fewer than 1% of all the patients.

A comparison of participants versus nonparticipants is shown in Table 1. The mean age of surveyed patients was 60.1 years, and 57% were female. The most common categories of insurance coverage were Medicare and HMO. The inpatient severity of illness of most patients was minor to moderate. Self‐reported health status was normally distributed, with the greatest percentage of patients rating their health as fair or good. On average, nonparticipants were younger than participants, more likely to be male, had a different pattern of health insurance, and a slightly lower severity of illness. The top 10 DRGs were the same for the respondents and nonrespondents, and the order of these 10 diagnoses was very similar.

Of the 15,767 patients contacted, 11.9% (N = 1876) reported symptoms that were new or had worsened since leaving the hospital. Sixty‐four percent of these patients had new symptoms, and 36% had worsening symptoms. These two groups were combined for analysis in this study because for both groups, identification and action are important. Of the patients with new or worse symptoms, 37% required no assistance from the nurse because they had already notified a doctor and/or were doing something about it. The other 63% either had not notified their doctor or had concerns about their signs and symptoms. The most common action taken by the nurse was patient education regarding the symptoms. Of those requiring nurse intervention in addition to education, the most common intervention was to contact the patient's primary care provider or specialist about the patient's symptoms, followed by contacting the hospitalist. In 72% of nurse interventions, the patient's primary care physician or a specialist was contacted about the new or worsened symptoms. Other interventions included contacting the physician's office to obtain a prescription for a medication for the symptom, to get an appointment for the patient, or to reschedule an appointment to be earlier. A referral to an emergency room or urgent care center was given to 4% of patients.

Mean age of the patients with new or worsened symptoms was 60.5 years. The age distribution of symptomatic and asymptomatic patients was not significantly different, whether comparing by mean, median, or decades. Table 2 illustrates factors associated with the increased rate of new or worsened symptoms. Women were more likely than men to report symptoms (13.0% vs. 10.3%, P < .0001). As health status worsened, the percentage of patients with new or worsened symptoms increased (P < .0001), as it did with increased inpatient SOI (P < .0001). There was no correlation between self‐rated health status and SOI score based on DRG score, suggesting they measured different parameters. Table 3 lists the percentages of patients reporting new or worsened symptoms for the most common DRGs. The only significant distinction was that patients discharged with a DRG of chest pain were less likely to report symptoms than were all patients.

The symptoms the patients reported are categorized in Table 4 without distinction as to whether they are primary or secondary. Gastrointestinal symptoms were the most common category of symptoms, followed by general symptoms, cardiovascular symptoms, and pain. The most common symptoms reported were fatigue/weakness, nausea/vomiting, and edema.

The call center assessed whether the patient had difficulty making a follow‐up appointment and whether an appointment was scheduled within 2 weeks of discharge. Patients with new or worsening symptoms were only minimally more likely to have scheduled follow‐up (61.0% vs. 58.4% for patients not reporting new or worsening symptoms, P < .05). Symptomatic patients had a higher prevalence of medication issues, defined as not picking up their prescriptions or not understanding how to take their medication (22.2% vs. 6.8% for asymptomatic patients; P < .0001). Likewise, the prevalence of symptomatic patients having problems receiving scheduled home health care services was 5.8%, compared with a prevalence of 3.6% for asymptomatic patients (P < .0001).

DISCUSSION

Enhancing the quality of care provided by hospitalists means not only improving care during hospitalization but also assuring patient stability between discharge and outpatient follow‐up. As part of efforts to improve transition management, the call center at IPC attempted to contact all patients discharged home within several days of discharge. Of 15,767 patients surveyed between May 1, 2003, and October 31, 2003, 11.9% (N = 1876) had new or worsening symptoms since leaving the hospital only 2 or 3 days earlier. We had hypothesized that older patients might be more symptomatic than younger ones, but found no difference in the prevalence of new or worsening symptoms based on age. Women were more likely to be symptomatic than men.

We defined appropriate postdischarge follow‐up as having an appointment with an outpatient physician within 2 weeks. A previous study of psychiatric patients documented that keeping a follow‐up appointment significantly reduces the risk of rehospitalization.17 Similar data do not exist for medical patients. Our data demonstrated that symptomatic patients were only minimally more likely to have made a follow‐up appointment with their outpatient physician within the first 2 weeks than were those patients who were not symptomatic. As part of patient education at discharge, clinicians routinely counsel patients to call their outpatient physician should they experience new or worsening symptoms once at home. Inpatient physicians may assume this recommendation provides a safety net for the patients should they develop problems after discharge. However, our finding that almost 40% of patients with new or worsening symptoms within 2‐3 days of discharge had not made a follow‐up appointment with their physician suggests many patients fall through this safety net. Although there was a slight statistically significant difference between the groups, this difference was not clinically significant. One potential limitation of our data is that we did not examine whether there was a correlation between the day of the week that a patient was discharged and inability to make a follow‐up appointment.

As part of the survey script (see Appendix), we inquired whether patients were able to pick up their prescriptions and whether they understood how to take their medication. A high percentage of patients in our study reported having one of these medication issues in the first several days following hospital discharge, providing an opportunity for early intervention and prevention of medical error. Forster and others have demonstrated that adverse events and medical errors are common in the postdischarge period, affecting 23%‐49% of patients.79 Errors in the transition from inpatient to outpatient care increased the 3‐month rate of rehospitalization.9 New or worsening symptoms represented the most common adverse event.8 Noting that many of these postdischarge complications could be preventable if detected early, Forster suggested system changes such as earlier follow‐up with the outpatient physician or a postdischarge telephone call to check on the patient's status.7, 18 Future studies are planned to further analyze our data on medication issues and to determine if these problems are more prevalent for certain medications or diagnoses.

Comprehensive discharge planning remains an essential step in the discharge process. This may involve prescribing medications, arranging home health care services, and arranging outpatient follow‐up. The traditional hospital discharge process does not adequately ensure that patients understand their discharge plan and are able to comply with it. Calkins et al. compared physicians' perceptions of patients' understanding of medication side effects and activity restrictions with patients' actual understanding.6 They found that, compared with what was reported by patients, physicians overestimated the time spent discussing discharge plans and how well patients understood medication side effects and activity restrictions.

An important method for reducing patient problems is to contact patients by telephone after discharge in order to identify any health care issues. Previous research has confirmed that follow‐up telephone calls improve health outcomes and decrease resource utilization of patients, mainly those discharged from the emergency department.10, 11, 1923 A study of telephone follow‐up after ambulatory care visits did not find significant benefits of this procedure.24 In one of the few studies of telephone calls after hospitalization, pharmacists contacted patients 2 days after discharge and were able to detect and resolve medication‐related problems in 19% of patients and learned of new or worsening symptoms in 15%. Patient satisfaction was improved, and the intervention resulted in a lower rate of repeat visits to the emergency room within 30 days of discharge.12 Another study of telephone follow‐up following hospital discharge compared proactively calling all patients with providing a phone number that patients can call if they have questions. The study demonstrated that very few patients called the number provided, but of those patients called by the nursing service, more than 90% had questions about self‐care and recovery.25 These findings demonstrate the value of proactively contacting patients in the first several days after discharge, when problems can be detected and interventions initiated earlier.

One potential concern with this study was the low response rate. This was a retrospective analysis of an existing discharge management call‐center system, not a prospective study. We were not able to reach 52% of the patients discharged after 2 attempts by telephone. To have our call center make additional attempts to reach each patient by telephone would require a significant increase in the size of the call center, because at the time of the study, the staff was handling more than 370 patients discharged home a day. The telephone number of 16% of patients was missing or incorrect. We have since developed internal quality improvement mechanisms to decrease this percentage. After subtracting the patients we were unable to reach and those whose phone number was missing or incorrect, we were able to contact 32.4% of all the patients discharged home.

Several reasons explain the response rate found by many prospective research studies. In most studies of telephone follow‐up, patients must be able to consent to participate in order to be considered eligible inclusion. This raises the response rate because patients who do not consent to participate, have language barriers, or have no telephone are excluded from the study. In our study none of these types of patients were excluded. There are 2 additional differences between our study and many published studies that involve telephone surveys. Ours was not a prospective research study, and we contacted many more patients than did other studies. For example, a study by Forster et al. involved only 581 patients, and the research staff was diligent in its efforts to reach the patients,7 making up to 20 attempts for each patient. They reported a response rate of 69%. If they had included patients who were non‐English speakers or had no phone in their study, the response rate would have been 59%. Shesser et al. were able to reach 144 of 297 patients in their study of emergency room follow‐up, for a 48.4% response rate.25 The response rate in a study of telephone consultation with asthma patients was quite similar to ours. They enrolled 932 eligible patients, of whom they were able to reach 278, for a response rate of 30%.

It is possible that the rate of symptoms and the other variables we measured relative to this would have been different if we had been able to reach 100% of patients. There were some demographic differences between the patients we were able to reach and those we were not (Table 1). The nonresponders were slightly younger and slightly more likely to be female. Nonresponders were more likely to have Medicaid or commercial insurance or be self‐pay and were less likely to have Medicare. In addition, nonresponders had less severe illness. Although this scenario is highly unlikely, if none of the nonresponders had new or worsening symptoms, the rate of symptoms would only have been 3.86%. Conversely, it is possible but also very unlikely that a greater percentage of the nonresponders had new or worsening symptoms. Given the demographics of our study participants, we would expect a potentially slightly lower rate of signs and symptoms.

The present study had several other limitations. First, all patients surveyed were cared for by IPC‐employed physicians. It is possible that reported rates of symptoms and other postdischarge issues are not generalizable to other hospitalist practices. However, the present data were collected at more than 100 health care facilities in 10 health care markets, and the patients were cared for by more than 200 physicians. Therefore, it is unlikely these results would have been significantly influenced by a particular physician's or institution's practice patterns.

Second, because of the large number of facilities involved and that we could only track readmissions to facilities where our own hospitalists practice, we were not able to report 30‐ or 90‐day readmission rates or emergency room visit rates. In a prospective study, these would be important variables to track in order to assess the clinical relevance of the symptoms. We could track this data for some institutions, but for most of them, the quality of data was not sufficient to be meaningful or to make conclusions.

An additional limitation is that the call center did not differentiate between clinically minor and major symptoms. The inclusion of symptoms perhaps considered minor might have elevated the reported symptom frequency. However, the definitions of minor and major symptoms are very subjective, and a clinician's definitions might differ from those of a patient who is at home and uncomfortable. For example, nausea or loss of appetite related to new medications may be considered minor clinically but could be devastating to the patient experiencing them, leading the patient to stop taking the medication. Conversely, symptoms that may be considered nonsignificant by the patient may be interpreted as indicating clinically significant disease by a physician. Therefore, we would argue that, regardless of the severity of the symptom, follow‐up with a clinician is important.

Another limitation is based on our definition of an adequate follow‐up appointment as one scheduled within 2 weeks of discharge. It might be argued that if a patient's new symptoms were considered minor clinically, then a follow‐up interval greater than 2 weeks might be considered adequate. However, as already noted, a patient's criteria for considering a symptom minor and not requiring follow‐up may differ from a clinician's criteria. Also, the standardized discharge process requires that the hospitalist identify a physician for outpatient follow‐up and specify the period when the patient is to see the physician. Because of the inherent variability in having a many hospitalists practicing in many hospitals, not all patients had a scheduled appointment at discharge. We were not able to determine whether patients had an appointment date and time for follow‐up before discharge or had only received instructions to call the office for an appointment.

The Institute of Medicine, in its report Crossing the Quality Chasm, identified the coordination of care across services and sites of care as one of the health care system's redesign imperatives.2 Hospitalists are in a unique position to address transition care issues. Managing the transition from inpatient to outpatient care is vitally important, and hospitalists should play an essential role in designing a transition management system for discharged patients. Although individual efforts by hospitalists are essential to assuring postdischarge contact with patients, there is increasing agreement that system solutions are needed to improve the quality of care in the transition period following hospitalization. Improving a health care process involves more than working harder; it involves working differently.3 It is therefore imperative that hospitalist programs develop effective systems to manage the transition period until safe arrival by the patient in the outpatient physician's office.

In summary, 11.9% of patients contacted by a telephone call center within several days of discharge had new or worsening symptoms since discharge. There was no difference by age in the prevalence of symptoms. Patients who rated their health status as fair to poor were more likely to be symptomatic. Symptomatic patients were also more likely to have difficulty obtaining or understanding how to take their medications and receiving home health services. Patients who felt poorly were only minimally more likely to have made an appointment for follow‐up with their outpatient physician. It is hoped that by identifying patients who are doing poorly after discharge and intervening as necessary, we can improve the health outcome of our patients, as well as reduce the number of emergency room visits and readmission rates. Although actions by individual physicians are important, a system to manage the postdischarge transition period is essential for improving posthospitalization outcomes.

Soon after they form, most new medical fields begin agitating for a special certification, something that says, We're here, and we're different. As I've noted previously in the Journal of Hospital Medicine, the field of hospital medicine resisted this impulse in its early years, fearing that any special designation or certification would actually harm the field's growth and status.1 The concern was that managed‐care organizationsconvinced by the evidence that hospitalists improve efficiency and might improve quality2would react to any new hospitalist sheepskin by mandating that anyone providing hospital care to its covered patients have one. The backlash from primary care physicians locked out of the hospital by such a mandate would have been swift and ultimately damaging to hospitalists. In addition to these political considerations, the early field of hospital medicine lacked the academic credibility and scientific underpinning needed for specialty designation.3

Times have changed. There are now more than 15,000 hospitalists in the United States, and nearly half of American hospitals have hospitalists on their medical staffs. In many markets, including my own, hospitalists care for most internal medicine inpatients, as well as significant numbers of pediatric and surgical patients. The field has achieved academic legitimacy, with this journal, several textbooks, large and flourishing groups in every academic medical center, and several residency tracks and fellowship programs.4, 5 The Society of Hospital Medicine (SHM) has grown to more than 6000 members, become a widely respected and dynamic member of the community of professional societies, and published its core competencies.6

With this as a background, in 2004 SHM asked the American Board of Internal Medicine (ABIM) to consider a program of certification for hospitalists. As a past SHM president and now a member of the ABIM Board of Directors, I am privileged to have a bird's‐eye view of the process. In this article, I reflect on some of the key issues it raises.

THE NUTS AND BOLTS OF BOARD CERTIFICATION

Since the first board (ophthalmology) was formed in 1917, 24 specialty boards have emerged, all under the umbrella of the American Board of Medical Specialties (ABMS).7 Because no one type of physician can do it all, certifying boards have had to struggle not only with how to assess competency in existing disciplines, but with the dynamic and often controversial questions raised when new fields emerge. In the past few decades, certifying boards have grappled with specialties formed around new procedures (such as cardiac electrophysiology), discrete populations (geriatrics, palliative care), complex diseases (HIV medicine), and sites of care (intensive care medicine, emergency medicine). It is this latter category that now includes hospital medicine.

In the past, it was relatively simple for a physician to obtain board certification. Residency or fellowship training was believed to confer on its graduates the presumption of competence and professionalismthe program director's attestation served as the graduate's Good Housekeeping seal of approval. Passing the board exam was the final step, ensuring that newly minted graduates had the requisite knowledge and judgment to practice in their fields.

Remarkably, for the first half century of the specialty boards, all certifications lasted for a physician's professional lifetime. Beginning with the 1969 decision of the American Board of Family Practice to limit the validity of its certificates to 7 years, all ABMS member boards now time limit their certifications, usually to 7‐10 years.7 Of course, in an environment of rapidly changing medical knowledge and new procedures, periodiceven continuousdemonstration of competence is increasingly expected by the public.

For ABIM, the mechanism to promote lifelong learning and demonstrate ongoing competence in the face of a rapidly changing environment is known as maintenance of certification (MOC).8 Through MOC, board‐certified internists demonstrate their ongoing clinical expertise and judgment, their involvement in lifelong learning and quality improvement activities, and their professionalism. Because MOC involves no new training requirements and includes an assessment of a physician's actual practice, it provides a potential mechanism, heretofore untapped, of demonstrating a unique professional focus that emerges after the completion of formal training.

HOSPITALIST CERTIFICATION AND THE MOC PROCESS

As ABIM considered a separate certification pathway for hospital medicine, it faced a conundrum. The vast majority of hospitalists are general internists (most of the rest are generalists in family medicine or pediatrics) who entered hospital medicine at the completion of their internal medicine training or after a period of primary care practice. Job opportunities for hospitalists are plentiful, andexcept for additional training in quality improvement, systems leadership, care transitions, palliative care, and communication9there is little clinical rationale to prolong internal medicine training for hospitalists (some individuals may opt for fellowships to enhance their leadership skills or to launch a research career,5 but few would argue for mandatory additional clinical training in hospital medicine at this time).

So, in the absence of formal training, how could the ABIM (or other boards) recognize the focused practice of hospitalists? This question must be framed within a broader challenge: Is it possible and appropriate for certifying boards to recognize expertise and focus that is accrued not through formal training, but through actual practice experience and accompanying self‐directed learning?

In 2006, the ABIM took up this question, producing a report (New and Emerging Disciplines in Internal Medicine II [NEDIM II]) that delineated several criteria to guide whether a new field merited focused recognition through MOC (Table 1). Judging by these criteria, hospital medicine appears to be a suitable first candidate for recognition of focused practice through MOC.

PRELIMINARY THOUGHTS ON FOCUSED RECOGNITION IN HOSPITAL MEDICINE

The ABIM has endorsed the concept of recognition of focused practice in hospital medicine and charged a subcommittee (that I chair) with working out the details. It would be premature to describe the committee's deliberations in detail (particularly because the final plan needs to be approved by both the ABIM and the ABMS), but the following are some key issues being discussed.

First, demonstration of focused practice requires some minimum volume of hospitalized patients. In the absence of hard data defining a threshold number of cases for hospitalists, we are likely to endorse a number that has face validity and that reliably separates self‐identified hospitalists from nonhospitalist generalists. As with all volume requirements, we will struggle over how to handle academic physicians, physician‐administrators, and physician‐researchers who limit their overall clinical practice but who spend most of their clinical time in hospital medicine and the bulk of their nonclinical time trying to improve hospital care.

The requirements to demonstrate performance in practice and lifelong learning may be more straightforward. As with all such MOC requirements, the ABIM is increasingly looking to use real practice data, trying to harmonize its data requirements with those of other organizations such as insurers, Medicare, the Joint Commission, or for pay‐for‐performance initiatives. Despite the operational challenges, this effort is vital: for MOC (including focused recognition) to be highly valued by patients, purchasers, and diplomates, it will increasingly need to measure not only what physicians know, but also what they do.

Finally, there is the test. It is likely that a secure exam for MOC with Recognition of Focused Practice in Hospital Medicine will involve core content in internal medicine (information that every internist should know), augmented by substantial and challenging content in hospital medicine. Because it will be vital that a competent hospitalist understand key elements of outpatient practice, the exam will not be stripped of ambulatory content but will likely have fewer questions on topics that hospitalists are unlikely to confront (osteoporosis, cancer screening).

ONGOING ISSUES

As hospital medicine continues its explosive growth, it is important to develop ways to make board certification relevant to hospitalists. The ABIM believes that modifying the MOC process to recognize physicians who have focused their practice and achieved special expertise in hospital medicine is a good way to launch this effort. Ultimately, this process is likely to evolve, particularly if separate training pathways for hospital medicine emerge. For now, the development of Recognition of Focused Practice in Hospital Medicine will further legitimize the new field, provide ABIM with insights into how to recognize physicians who have advanced through practice‐based learning rather than through training, and help to guide other certifying boards (particularly family medicine and pediatrics) considering hospitalist certification. In the end, the process will need to be user‐friendly for and satisfying to diplomates, flexible enough to allow for career transitions (both toward and away from hospital medicine), and sufficiently rigorous to be credible to all stakeholders, particularly patients.

Soon after they form, most new medical fields begin agitating for a special certification, something that says, We're here, and we're different. As I've noted previously in the Journal of Hospital Medicine, the field of hospital medicine resisted this impulse in its early years, fearing that any special designation or certification would actually harm the field's growth and status.1 The concern was that managed‐care organizationsconvinced by the evidence that hospitalists improve efficiency and might improve quality2would react to any new hospitalist sheepskin by mandating that anyone providing hospital care to its covered patients have one. The backlash from primary care physicians locked out of the hospital by such a mandate would have been swift and ultimately damaging to hospitalists. In addition to these political considerations, the early field of hospital medicine lacked the academic credibility and scientific underpinning needed for specialty designation.3

Times have changed. There are now more than 15,000 hospitalists in the United States, and nearly half of American hospitals have hospitalists on their medical staffs. In many markets, including my own, hospitalists care for most internal medicine inpatients, as well as significant numbers of pediatric and surgical patients. The field has achieved academic legitimacy, with this journal, several textbooks, large and flourishing groups in every academic medical center, and several residency tracks and fellowship programs.4, 5 The Society of Hospital Medicine (SHM) has grown to more than 6000 members, become a widely respected and dynamic member of the community of professional societies, and published its core competencies.6

With this as a background, in 2004 SHM asked the American Board of Internal Medicine (ABIM) to consider a program of certification for hospitalists. As a past SHM president and now a member of the ABIM Board of Directors, I am privileged to have a bird's‐eye view of the process. In this article, I reflect on some of the key issues it raises.

THE NUTS AND BOLTS OF BOARD CERTIFICATION

Since the first board (ophthalmology) was formed in 1917, 24 specialty boards have emerged, all under the umbrella of the American Board of Medical Specialties (ABMS).7 Because no one type of physician can do it all, certifying boards have had to struggle not only with how to assess competency in existing disciplines, but with the dynamic and often controversial questions raised when new fields emerge. In the past few decades, certifying boards have grappled with specialties formed around new procedures (such as cardiac electrophysiology), discrete populations (geriatrics, palliative care), complex diseases (HIV medicine), and sites of care (intensive care medicine, emergency medicine). It is this latter category that now includes hospital medicine.

In the past, it was relatively simple for a physician to obtain board certification. Residency or fellowship training was believed to confer on its graduates the presumption of competence and professionalismthe program director's attestation served as the graduate's Good Housekeeping seal of approval. Passing the board exam was the final step, ensuring that newly minted graduates had the requisite knowledge and judgment to practice in their fields.

Remarkably, for the first half century of the specialty boards, all certifications lasted for a physician's professional lifetime. Beginning with the 1969 decision of the American Board of Family Practice to limit the validity of its certificates to 7 years, all ABMS member boards now time limit their certifications, usually to 7‐10 years.7 Of course, in an environment of rapidly changing medical knowledge and new procedures, periodiceven continuousdemonstration of competence is increasingly expected by the public.

For ABIM, the mechanism to promote lifelong learning and demonstrate ongoing competence in the face of a rapidly changing environment is known as maintenance of certification (MOC).8 Through MOC, board‐certified internists demonstrate their ongoing clinical expertise and judgment, their involvement in lifelong learning and quality improvement activities, and their professionalism. Because MOC involves no new training requirements and includes an assessment of a physician's actual practice, it provides a potential mechanism, heretofore untapped, of demonstrating a unique professional focus that emerges after the completion of formal training.

HOSPITALIST CERTIFICATION AND THE MOC PROCESS

As ABIM considered a separate certification pathway for hospital medicine, it faced a conundrum. The vast majority of hospitalists are general internists (most of the rest are generalists in family medicine or pediatrics) who entered hospital medicine at the completion of their internal medicine training or after a period of primary care practice. Job opportunities for hospitalists are plentiful, andexcept for additional training in quality improvement, systems leadership, care transitions, palliative care, and communication9there is little clinical rationale to prolong internal medicine training for hospitalists (some individuals may opt for fellowships to enhance their leadership skills or to launch a research career,5 but few would argue for mandatory additional clinical training in hospital medicine at this time).

So, in the absence of formal training, how could the ABIM (or other boards) recognize the focused practice of hospitalists? This question must be framed within a broader challenge: Is it possible and appropriate for certifying boards to recognize expertise and focus that is accrued not through formal training, but through actual practice experience and accompanying self‐directed learning?

In 2006, the ABIM took up this question, producing a report (New and Emerging Disciplines in Internal Medicine II [NEDIM II]) that delineated several criteria to guide whether a new field merited focused recognition through MOC (Table 1). Judging by these criteria, hospital medicine appears to be a suitable first candidate for recognition of focused practice through MOC.

PRELIMINARY THOUGHTS ON FOCUSED RECOGNITION IN HOSPITAL MEDICINE

The ABIM has endorsed the concept of recognition of focused practice in hospital medicine and charged a subcommittee (that I chair) with working out the details. It would be premature to describe the committee's deliberations in detail (particularly because the final plan needs to be approved by both the ABIM and the ABMS), but the following are some key issues being discussed.

First, demonstration of focused practice requires some minimum volume of hospitalized patients. In the absence of hard data defining a threshold number of cases for hospitalists, we are likely to endorse a number that has face validity and that reliably separates self‐identified hospitalists from nonhospitalist generalists. As with all volume requirements, we will struggle over how to handle academic physicians, physician‐administrators, and physician‐researchers who limit their overall clinical practice but who spend most of their clinical time in hospital medicine and the bulk of their nonclinical time trying to improve hospital care.

The requirements to demonstrate performance in practice and lifelong learning may be more straightforward. As with all such MOC requirements, the ABIM is increasingly looking to use real practice data, trying to harmonize its data requirements with those of other organizations such as insurers, Medicare, the Joint Commission, or for pay‐for‐performance initiatives. Despite the operational challenges, this effort is vital: for MOC (including focused recognition) to be highly valued by patients, purchasers, and diplomates, it will increasingly need to measure not only what physicians know, but also what they do.

Finally, there is the test. It is likely that a secure exam for MOC with Recognition of Focused Practice in Hospital Medicine will involve core content in internal medicine (information that every internist should know), augmented by substantial and challenging content in hospital medicine. Because it will be vital that a competent hospitalist understand key elements of outpatient practice, the exam will not be stripped of ambulatory content but will likely have fewer questions on topics that hospitalists are unlikely to confront (osteoporosis, cancer screening).

ONGOING ISSUES

As hospital medicine continues its explosive growth, it is important to develop ways to make board certification relevant to hospitalists. The ABIM believes that modifying the MOC process to recognize physicians who have focused their practice and achieved special expertise in hospital medicine is a good way to launch this effort. Ultimately, this process is likely to evolve, particularly if separate training pathways for hospital medicine emerge. For now, the development of Recognition of Focused Practice in Hospital Medicine will further legitimize the new field, provide ABIM with insights into how to recognize physicians who have advanced through practice‐based learning rather than through training, and help to guide other certifying boards (particularly family medicine and pediatrics) considering hospitalist certification. In the end, the process will need to be user‐friendly for and satisfying to diplomates, flexible enough to allow for career transitions (both toward and away from hospital medicine), and sufficiently rigorous to be credible to all stakeholders, particularly patients.

Soon after they form, most new medical fields begin agitating for a special certification, something that says, We're here, and we're different. As I've noted previously in the Journal of Hospital Medicine, the field of hospital medicine resisted this impulse in its early years, fearing that any special designation or certification would actually harm the field's growth and status.1 The concern was that managed‐care organizationsconvinced by the evidence that hospitalists improve efficiency and might improve quality2would react to any new hospitalist sheepskin by mandating that anyone providing hospital care to its covered patients have one. The backlash from primary care physicians locked out of the hospital by such a mandate would have been swift and ultimately damaging to hospitalists. In addition to these political considerations, the early field of hospital medicine lacked the academic credibility and scientific underpinning needed for specialty designation.3

Times have changed. There are now more than 15,000 hospitalists in the United States, and nearly half of American hospitals have hospitalists on their medical staffs. In many markets, including my own, hospitalists care for most internal medicine inpatients, as well as significant numbers of pediatric and surgical patients. The field has achieved academic legitimacy, with this journal, several textbooks, large and flourishing groups in every academic medical center, and several residency tracks and fellowship programs.4, 5 The Society of Hospital Medicine (SHM) has grown to more than 6000 members, become a widely respected and dynamic member of the community of professional societies, and published its core competencies.6

With this as a background, in 2004 SHM asked the American Board of Internal Medicine (ABIM) to consider a program of certification for hospitalists. As a past SHM president and now a member of the ABIM Board of Directors, I am privileged to have a bird's‐eye view of the process. In this article, I reflect on some of the key issues it raises.

THE NUTS AND BOLTS OF BOARD CERTIFICATION

Since the first board (ophthalmology) was formed in 1917, 24 specialty boards have emerged, all under the umbrella of the American Board of Medical Specialties (ABMS).7 Because no one type of physician can do it all, certifying boards have had to struggle not only with how to assess competency in existing disciplines, but with the dynamic and often controversial questions raised when new fields emerge. In the past few decades, certifying boards have grappled with specialties formed around new procedures (such as cardiac electrophysiology), discrete populations (geriatrics, palliative care), complex diseases (HIV medicine), and sites of care (intensive care medicine, emergency medicine). It is this latter category that now includes hospital medicine.

In the past, it was relatively simple for a physician to obtain board certification. Residency or fellowship training was believed to confer on its graduates the presumption of competence and professionalismthe program director's attestation served as the graduate's Good Housekeeping seal of approval. Passing the board exam was the final step, ensuring that newly minted graduates had the requisite knowledge and judgment to practice in their fields.

Remarkably, for the first half century of the specialty boards, all certifications lasted for a physician's professional lifetime. Beginning with the 1969 decision of the American Board of Family Practice to limit the validity of its certificates to 7 years, all ABMS member boards now time limit their certifications, usually to 7‐10 years.7 Of course, in an environment of rapidly changing medical knowledge and new procedures, periodiceven continuousdemonstration of competence is increasingly expected by the public.

For ABIM, the mechanism to promote lifelong learning and demonstrate ongoing competence in the face of a rapidly changing environment is known as maintenance of certification (MOC).8 Through MOC, board‐certified internists demonstrate their ongoing clinical expertise and judgment, their involvement in lifelong learning and quality improvement activities, and their professionalism. Because MOC involves no new training requirements and includes an assessment of a physician's actual practice, it provides a potential mechanism, heretofore untapped, of demonstrating a unique professional focus that emerges after the completion of formal training.

HOSPITALIST CERTIFICATION AND THE MOC PROCESS

As ABIM considered a separate certification pathway for hospital medicine, it faced a conundrum. The vast majority of hospitalists are general internists (most of the rest are generalists in family medicine or pediatrics) who entered hospital medicine at the completion of their internal medicine training or after a period of primary care practice. Job opportunities for hospitalists are plentiful, andexcept for additional training in quality improvement, systems leadership, care transitions, palliative care, and communication9there is little clinical rationale to prolong internal medicine training for hospitalists (some individuals may opt for fellowships to enhance their leadership skills or to launch a research career,5 but few would argue for mandatory additional clinical training in hospital medicine at this time).

So, in the absence of formal training, how could the ABIM (or other boards) recognize the focused practice of hospitalists? This question must be framed within a broader challenge: Is it possible and appropriate for certifying boards to recognize expertise and focus that is accrued not through formal training, but through actual practice experience and accompanying self‐directed learning?

In 2006, the ABIM took up this question, producing a report (New and Emerging Disciplines in Internal Medicine II [NEDIM II]) that delineated several criteria to guide whether a new field merited focused recognition through MOC (Table 1). Judging by these criteria, hospital medicine appears to be a suitable first candidate for recognition of focused practice through MOC.

PRELIMINARY THOUGHTS ON FOCUSED RECOGNITION IN HOSPITAL MEDICINE

The ABIM has endorsed the concept of recognition of focused practice in hospital medicine and charged a subcommittee (that I chair) with working out the details. It would be premature to describe the committee's deliberations in detail (particularly because the final plan needs to be approved by both the ABIM and the ABMS), but the following are some key issues being discussed.

First, demonstration of focused practice requires some minimum volume of hospitalized patients. In the absence of hard data defining a threshold number of cases for hospitalists, we are likely to endorse a number that has face validity and that reliably separates self‐identified hospitalists from nonhospitalist generalists. As with all volume requirements, we will struggle over how to handle academic physicians, physician‐administrators, and physician‐researchers who limit their overall clinical practice but who spend most of their clinical time in hospital medicine and the bulk of their nonclinical time trying to improve hospital care.

The requirements to demonstrate performance in practice and lifelong learning may be more straightforward. As with all such MOC requirements, the ABIM is increasingly looking to use real practice data, trying to harmonize its data requirements with those of other organizations such as insurers, Medicare, the Joint Commission, or for pay‐for‐performance initiatives. Despite the operational challenges, this effort is vital: for MOC (including focused recognition) to be highly valued by patients, purchasers, and diplomates, it will increasingly need to measure not only what physicians know, but also what they do.

Finally, there is the test. It is likely that a secure exam for MOC with Recognition of Focused Practice in Hospital Medicine will involve core content in internal medicine (information that every internist should know), augmented by substantial and challenging content in hospital medicine. Because it will be vital that a competent hospitalist understand key elements of outpatient practice, the exam will not be stripped of ambulatory content but will likely have fewer questions on topics that hospitalists are unlikely to confront (osteoporosis, cancer screening).

ONGOING ISSUES

As hospital medicine continues its explosive growth, it is important to develop ways to make board certification relevant to hospitalists. The ABIM believes that modifying the MOC process to recognize physicians who have focused their practice and achieved special expertise in hospital medicine is a good way to launch this effort. Ultimately, this process is likely to evolve, particularly if separate training pathways for hospital medicine emerge. For now, the development of Recognition of Focused Practice in Hospital Medicine will further legitimize the new field, provide ABIM with insights into how to recognize physicians who have advanced through practice‐based learning rather than through training, and help to guide other certifying boards (particularly family medicine and pediatrics) considering hospitalist certification. In the end, the process will need to be user‐friendly for and satisfying to diplomates, flexible enough to allow for career transitions (both toward and away from hospital medicine), and sufficiently rigorous to be credible to all stakeholders, particularly patients.

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 _AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 _PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 _AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 _PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 _AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 _PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

A 56‐year‐old woman from Colombia presented to the emergency department after 24 hours of abdominal pain. One week before, she had experienced similar pain that lasted for 4 hours and spontaneously resolved. She was nauseated but had no vomiting. She reported an unintentional 14‐pound weight loss over the preceding 3 weeks. She denied fever, chills, night sweats, diarrhea, constipation, dysuria, or jaundice.

In a middle‐aged woman with abdominal pain and nausea, diagnostic considerations include gallbladder disease, diseases of the bowel (such as a partial small‐bowel obstruction or inflammatory conditions), hepatic or pancreatic conditions, and nongastrointestinal ailments such as cardiac ischemia. Knowing the specific location of pain, its quality, precipitating factors, and accompanying systemic symptoms may help to narrow the diagnosis. The unintentional weight loss preceding the onset of pain may be an important clue because it suggests a systemic condition, and in a South American immigrantparticularly if she has traveled recentlyit is important to consider parasitic illnesses. The absence of fever makes some infections such as tuberculosis and malaria less likely. At this point, in addition to a thorough history and physical, laboratory tests should include a complete blood count (with quantification of eosinophils) and a metabolic panel with liver enzymes and albumin.

The patient described pain in the midline, just inferior to the umbilicus. The pain was constant, developed without any particular provocation, and was not related to meals or exertion. There were no constitutional symptoms aside from weight loss. She had a history of bipolar disorder, hypothyroidism, osteoarthritis, and chronic sinusitis and had previously undergone cholecystectomy and abdominal hysterectomy. She was taking levothyroxine, montelukast, bupropion, oxcarbazepine, fexofenadine, meloxicam, zolpidem, and, as needed, acetaminophen. She had recently completed a 10‐day course of levofloxacin for acute sinusitis. She had immigrated to the United States 10 years earlier and lived with her husband and daughter. She denied the use of tobacco, alcohol or illicit drugs. She had visited Colombia 6 months earlier but had no other recent travel history.

The history of cholecystectomy makes a biliary tract process unlikely. Its location reduces the likelihood of a hepatic or pancreatic process, but I would like to see the liver enzymes, especially given her recent acetaminophen use. The comorbid illnessesparticularly her bipolar disordermay be relevant because psychiatric illness might be associated with medication overuse or undisclosed toxic ingestions. For example, excess thyroxine might lead to weight loss while overuse of nonsteroidal anti‐inflammatory drugs such as meloxicam can cause intestinal ulceration, not only in the upper tract, but also in the colon. Undisclosed ingestions may also be associated with abdominal symptoms. Her surgical history makes adhesions with a secondary partial bowel obstruction possible. With no travel outside this country in the last 6 months, exotic infections are less likely. Finally, the recent course of levofloxacin may be relevant because many antibiotics are associated with nonspecific abdominal symptoms, and Clostridium difficile colitis occasionally presents without diarrhea.

The patient reported taking her medications as prescribed and denied ingesting other medications. On physical examination, she had a temperature of 98.9F, a pulse of 81 beats per minute, a blood pressure of 110/80 mm Hg, and a respiratory rate of 16 respirations per minute. She had a normal oxygen saturation while breathing ambient air. Her weight was 58 kg. There was no scleral icterus or jugular venous distension. She had a small painless ulcer involving the hard palate. Her lungs were clear to auscultation, and cardiac examination was normal. The abdomen was soft, bowel sounds were present, and there was moderate tenderness to palpation inferior to the umbilicus. There was no rebound or guarding, hepatosplenomegaly or other masses. There was no peripheral edema and no lymphadenopathy. Neurological examination was normal.

The oral ulcer may or may not be related to the clinical presentation because oral ulcers, whether painful or painless, are ubiquitous and may be isolated or may be associated with a wide range of infectious and noninfectious systemic diseases. Although some systemic causes of mucocutaneous ulcers are associated with weight loss (including Crohn's disease, Behcet's disease, celiac sprue, human immunodeficiency virus [HIV], herpesviruses, syphilis, and systemic lupus erythematosus [SLE], among others), the lack of specificity of this finding limits its diagnostic utility. However, it is reasonable to ask whether the patient has noted frequent ulceration in the mouth or genitalia, as recurrent or severe ulcerations may narrow the diagnostic considerations. On the other hand, the focal nature of the pain inferior to the umbilicus suggests a discrete process in the abdomen or pelvis, such as an abscess, mass, or localized area of bowel inflammation. A plain abdominal film is likely to be low yield in this situation, so pursuing computed tomography is appropriate. Not all patients with focal abdominal pain require abdominal imaging, but in the context of weight loss and persistent symptoms for more than a week, imaging is prudent in this case.

The patient denied genital ulceration but did report painless oral ulcers over the preceding months. Laboratory evaluation revealed a white‐cell count of 1000/mm³, of which 6% were neutrophils, 5% were band forms, 36% were lymphocytes, and 47% were monocytes. The absolute neutrophil count was 110/mm³. Hemoglobin level was 10.2 g/dL with a mean corpuscular volume of 90 m³, and the platelet count was 151,000/mm³. Other results of laboratory studies were: sodium, 140 mmol/L; potassium, 3.8 mmol/L; chloride, 96 mmol/L; bicarbonate, 23 mmol/L; blood urea nitrogen, 13 mg/dL; creatinine, 0.4 mg/dL; lipase, 32 U/L (normal range, 13‐60); amylase, 73 U/L (normal range, 30‐110); albumin, 4.0 g/dL; aspartate aminotransferase, 779 U/L (normal range, 13‐35); alanine aminotransferase, 330 U/L (normal range, 7‐35); alkaline phosphatase, 510 U/L (normal range, 35‐104); and total bilirubin, 0.9 mg/dL (normal range, 0.1‐1.2). The lactate dehydrogenase level was 200 U/L (normal range, 135‐214). The corrected reticulocyte count was 1.6% (normal range, 0.3‐2.3), and haptoglobin was 190 mg/dL (normal range, 43‐212). A direct Coomb's test was positive. The erythrocyte sedimentation rate was 113 mm/hour (normal range, 1‐25). Urinalysis was normal without evidence of protein or blood.

Laboratory abnormalities include elevated transaminases and alkaline phosphatase, a markedly elevated erythrocyte sedimentation rate, and profound leukopenia with neutropenia. The patient is anemic, which may elevate the sedimentation rate but not typically to this degree. The patient is not febrile, but if she were to develop a fever, empiric antibiotics would be prudent. The normal albumin and bilirubin suggest that hepatic synthetic and excretory functions remain intact. Although the direct Coombs test is positive, the reticulocyte and lactate dehydrogenase levels argue against brisk hemolysis; this abnormality may simply be a marker of nonspecific immune activation. A variety of infections can cause neutropenia and liver enzyme abnormalities including parasites (malaria or leishmaniasis), viruses (cytomegalovirus or Epstein‐Barr virus [EBV]), tick‐borne bacterial infections (ehrlichiosis or rickettsial infection), and granulomatous infections (tuberculosis). Malignant infiltration of the reticuloendothelial system can also lead to cytopenias and liver enzyme abnormalities. Autoimmunity remains a consideration, as SLE may lead to cytopenias, oral ulcers, and nonspecific immune phenomena. Rather than ordering a large number of blood tests, I favor a targeted approach with abdominal computed tomography followed by biopsy of either the liver or bone marrow.

Chest radiography revealed no abnormalities. Computed tomography of the chest, abdomen, and pelvis with intravenous and oral contrast demonstrated concentric wall thickening of the transverse colon, but no evidence of obstruction or free air. The patient was treated with intravenous fluids, morphine, and cefepime. Bone marrow biopsy was performed, which demonstrated a hypercellular marrow with increased myeloid precursors and a left shift and megakaryocytic hyperplasia. Flow cytometry revealed no abnormally restricted clonal populations. A concerted search for an infectious etiology of the patient's neutropenia was unrevealing, including tests for HIV, cytomegalovirus, hepatitis A, hepatitis B, hepatitis C, Mycoplasma pneumoniae, EBV, and parvovirus B19.

I hope blood cultures were drawn prior to the initiation of antibiotics. Hypercellularity of the bone marrow in the context of leukopenia raises concern that white blood cells are being destroyed peripherally. Autoimmunity against neutrophils can be transiently induced by viruses such as HIV, hepatitis B, and EBV, but these infections have been excluded. Testing for antinuclear antibodies is reasonable. A normal‐sized spleen on the abdominal CT excludes hypersplenism. Colonic thickening can be associated with infection, ischemia, inflammatory bowel disease, and malignancy. The question is whether the colonic thickening is part of the same disease process causing the leukopenia and liver enzyme elevation or whether it represents a secondary infectious process in the setting of neutropenia (such as Clostridium difficile infection or typhlitis). Testing for stool pathogens (including ova and parasites) is certainly appropriate, and consideration of a colonoscopy with biopsy is reasonable, provided that appropriate antimicrobial coverage remains in place.

Blood cultures obtained prior to starting antibiotics were negative. The patient's abdominal pain improved, and she was discharged home to have close follow‐up with a hematologist. The results of her liver function tests improved, and her absolute neutrophil count was 230/mm³ at the time of discharge. Her neutropenia was believed to be secondary to peripheral destruction from a viral, drug‐mediated, or autoimmune process. Oxcarbazepine (Trileptal) was discontinued, as it was believed to be the medication most likely to be responsible. She returned to the hospital 3 days later with recurrence of her abdominal pain and diarrhea. She remained afebrile. Additional history revealed arthralgias over the previous 2 months, mild alopecia, and prior symptoms suggestive of Raynaud's phenomenon. Stool studies failed to establish an infectious etiology for the diarrhea, and her continued neutropenia responded appropriately to treatment with subcutaneous filgrastim. Colonoscopy could be performed only to the hepatic flexure and revealed no abnormalities. A serologic test for antinuclear antibodies was positive at a titer of 1:640 in a homogenous pattern, and a test for antineutrophil cytoplasmic antibodies was negative. Complement levels were normal, and tests for cryoglobulins, rapid plasma reagin, anticardiolipin antibody, lupus anticoagulant, rheumatoid factor, and antibodies to extractable nuclear antigens were all negative.

Raynaud's phenomenon is consistent with lupus. Double‐stranded DNA antibodies should be sent, although the urine did not demonstrate protein or an active sediment. Systemic sclerosis and the CREST syndrome is strongly associated with Raynaud's phenomenon and high‐titer ANA, but the patient does not have sclerodactyly, which is generally the earliest skin involvement. Autoimmune hepatitis is often associated with high‐titer ANA but does not fit this clinical picture. Given that the patient's presentation included segmental bowel wall thickening and a transient but marked liver enzyme elevation with AST predominance, I am concerned about vasculitis of the abdominal vasculature and would strongly consider a mesenteric angiogram.

To exclude mesenteric vasculitis, the patient underwent magnetic resonance angiography of the abdomen, the results of which were normal. A repeat test for antinuclear antibodies was positive at a titer of 1:2560 in a uniform pattern. A test for anti‐double‐stranded DNA was positive at 1370 U/mL. The patient was diagnosed with systemic lupus and probable lupus enteritis, and therapy with oral prednisone (10 mg daily) and hydroxychloroquine was initiated. She had prompt improvement in her abdominal pain, and was discharged home. Five months later she developed proteinuria and underwent a renal biopsy, which showed minor, nonspecific glomerular abnormalities, suggesting possible mild lupus nephritis. Eight months after her initial presentation, she remains free of abdominal pain and has regained the weight she had initially lost. Her oral ulcers have resolved, and her blood counts have normalized. Her serum creatinine has remained normal. She is now maintained on prednisone (15 mg daily), hydroxychloroquine, and mycophenolate mofetil.

COMMENTARY

A diagnosis of systemic lupus erythematosus (SLE) provided a unifying explanation for the patient's findings. Indeed, she manifested 4 of the 11 American College of Rheumatology criteria for systemic lupus (oral ulcers, leukopenia, positive anti‐DNA, and positive ANA), meeting criteria for a definite diagnosis of SLE. She additionally had multiple other features suggestive of lupus including Raynaud's phenomenon, arthralgias, alopecia, mild thrombocytopenia, and a positive Coombs' test (although the normal reticulocyte count, lactate dehydrogenase, and haptoglobin were most consistent with anemia of a chronic disease).

The protean manifestations of SLE can present significant diagnostic challenges. In this case, physicians were immediately drawn to the patient's acute abdominal pain and severe neutropenia and failed to recognize more subtle disease manifestations that may have aided in establishing a unifying diagnosis sooner. The initial history and review of systems did not disclose arthralgias, alopecia, or Raynaud's phenomenon. In an era of increasing use of hospitalists, which creates potential discontinuity between inpatient and outpatient physicians, a thorough history and review of systems may be particularly important in diagnosing acute manifestations of chronic systemic disease. Inpatient physicians may be overly focused on the small subset of acute complaints leading to hospitalization, without considering the larger constellation of symptoms that may facilitate accurate diagnosis. Our discussant quickly recognized the multisystem nature of the patient's illness and appropriately focused on infectious, neoplastic, and autoimmune categories of disease as being most likely. When infectious and neoplastic conditions were excluded with reasonable certainty, a directed serologic investigation for autoimmune disease was requested, culminating in a diagnosis of SLE.

Involvement of the skin as well as hematologic, renal, and musculoskeletal systems in SLE is commonly recognized, whereas gastrointestinal involvement is perceived to occur much less frequently. However, abdominal pain occurs in up to 40% of patients with lupus.14 Abdominal pain in lupus patients can arise from non‐lupus‐related conditions as well as lupus‐related entities, including serositis, mesenteric vasculitis with or without infarction, mesenteric thrombosis, pancreatitis, inflammatory bowel disease, and adverse medication effects including peptic ulcer disease. Abnormal liver chemistries, as seen in our patient, occur in 20%‐50% of patients with lupus and may be due to lupus hepatitis, concomitant autoimmune hepatitis, or medications including NSAIDs.5, 6 Oral ulcers and leukopenia are likewise common in SLE, with each seen in up to half of patients.4, 7, 8 Leukopenia in SLE may a result of neutropenia, lymphocytopenia, or both. However, severe neutropenia (ie, absolute count less than 500/L), as seen in our case, is more often a result of myelotoxicity from immunosuppressive therapy, rather than SLE itself.9

Lupus enteritis represents bowel microischemia from small‐vessel arteritis or venulitis that often is not evident on conventional mesenteric angiography.4, 10, 11 The reported prevalence of intestinal vasculitis in patients with SLE varies widely, depending on the characteristics of lupus patients sampled in individual studies. Intestinal vasculitis affects 0.2%‐0.5% of SLE patients in general,4, 12 whereas among SLE patients with active disease and an acute abdomen, vasculitis has been reported in up to 53% of patients.10 Antiphospholipid antibodies, antibodies to extractable nuclear antigens, the SLE Disease Activity Index, complement levels, erythrocyte sedimentation rate, C‐reactive protein, and anti‐double‐stranded DNA do not reliably differentiate lupus enteritis from acute abdominal pain due to other etiologies in patients with SLE.11 However, a concomitant drop in the white blood cell count at the onset of symptoms may be useful in distinguishing lupus enteritis from other causes of acute abdominal pain among lupus patients.11 Computed tomography findings consistent with lupus enteritis are nonspecific and include bowel‐wall thickening, submucosal edema (eg, target sign), dilatation of intestinal segments, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat.13 Colonoscopy may reveal areas of ischemia and ulceration, and biopsy can confirm intestinal vasculitis. However, intestinal involvement may be segmental, and pathologic confirmation may be difficult. Contrast enema, gallium scanning, and indium‐labeled white cell scanning may be useful, but lack specificity. No controlled trials to date have evaluated the optimal therapy for lupus enteritis, but pulsed methylprednisolone is often recommended.4 Cyclophosphamide, azathioprine, methotrexate, and cyclosporine have also been used as adjunctive agents. Patients may progress to intestinal infarction and perforation, which augurs a poor prognosis, and early surgical exploration should be considered in severely ill patients.10 Death may occur in more than two‐thirds of patients whose disease progresses to intestinal perforation.1

In summary, a multisystem disease such as SLE requires a comprehensive history, physical exam, and review of systems to establish a correct diagnosis. In our case, an extensive evaluation was necessary to exclude other etiologies of abdominal pain and systemic illness, particularly as infectious and neoplastic conditions occur far more often than lupus enteritis in the general population. However, profound laboratory abnormalities may have preoccupied the attention of treating physicians, leading them to overlook less obvious but important historical and physical findings suggestive of SLE. The cohesively abnormal forest may thus have been obscured by erratically abnormal individual trees. Gastrointestinal symptoms may be underrecognized in SLE. When these result for lupus enteritis, timely recognition may be lifesaving.

A 56‐year‐old woman from Colombia presented to the emergency department after 24 hours of abdominal pain. One week before, she had experienced similar pain that lasted for 4 hours and spontaneously resolved. She was nauseated but had no vomiting. She reported an unintentional 14‐pound weight loss over the preceding 3 weeks. She denied fever, chills, night sweats, diarrhea, constipation, dysuria, or jaundice.

In a middle‐aged woman with abdominal pain and nausea, diagnostic considerations include gallbladder disease, diseases of the bowel (such as a partial small‐bowel obstruction or inflammatory conditions), hepatic or pancreatic conditions, and nongastrointestinal ailments such as cardiac ischemia. Knowing the specific location of pain, its quality, precipitating factors, and accompanying systemic symptoms may help to narrow the diagnosis. The unintentional weight loss preceding the onset of pain may be an important clue because it suggests a systemic condition, and in a South American immigrantparticularly if she has traveled recentlyit is important to consider parasitic illnesses. The absence of fever makes some infections such as tuberculosis and malaria less likely. At this point, in addition to a thorough history and physical, laboratory tests should include a complete blood count (with quantification of eosinophils) and a metabolic panel with liver enzymes and albumin.

The patient described pain in the midline, just inferior to the umbilicus. The pain was constant, developed without any particular provocation, and was not related to meals or exertion. There were no constitutional symptoms aside from weight loss. She had a history of bipolar disorder, hypothyroidism, osteoarthritis, and chronic sinusitis and had previously undergone cholecystectomy and abdominal hysterectomy. She was taking levothyroxine, montelukast, bupropion, oxcarbazepine, fexofenadine, meloxicam, zolpidem, and, as needed, acetaminophen. She had recently completed a 10‐day course of levofloxacin for acute sinusitis. She had immigrated to the United States 10 years earlier and lived with her husband and daughter. She denied the use of tobacco, alcohol or illicit drugs. She had visited Colombia 6 months earlier but had no other recent travel history.

The history of cholecystectomy makes a biliary tract process unlikely. Its location reduces the likelihood of a hepatic or pancreatic process, but I would like to see the liver enzymes, especially given her recent acetaminophen use. The comorbid illnessesparticularly her bipolar disordermay be relevant because psychiatric illness might be associated with medication overuse or undisclosed toxic ingestions. For example, excess thyroxine might lead to weight loss while overuse of nonsteroidal anti‐inflammatory drugs such as meloxicam can cause intestinal ulceration, not only in the upper tract, but also in the colon. Undisclosed ingestions may also be associated with abdominal symptoms. Her surgical history makes adhesions with a secondary partial bowel obstruction possible. With no travel outside this country in the last 6 months, exotic infections are less likely. Finally, the recent course of levofloxacin may be relevant because many antibiotics are associated with nonspecific abdominal symptoms, and Clostridium difficile colitis occasionally presents without diarrhea.

The patient reported taking her medications as prescribed and denied ingesting other medications. On physical examination, she had a temperature of 98.9F, a pulse of 81 beats per minute, a blood pressure of 110/80 mm Hg, and a respiratory rate of 16 respirations per minute. She had a normal oxygen saturation while breathing ambient air. Her weight was 58 kg. There was no scleral icterus or jugular venous distension. She had a small painless ulcer involving the hard palate. Her lungs were clear to auscultation, and cardiac examination was normal. The abdomen was soft, bowel sounds were present, and there was moderate tenderness to palpation inferior to the umbilicus. There was no rebound or guarding, hepatosplenomegaly or other masses. There was no peripheral edema and no lymphadenopathy. Neurological examination was normal.

The oral ulcer may or may not be related to the clinical presentation because oral ulcers, whether painful or painless, are ubiquitous and may be isolated or may be associated with a wide range of infectious and noninfectious systemic diseases. Although some systemic causes of mucocutaneous ulcers are associated with weight loss (including Crohn's disease, Behcet's disease, celiac sprue, human immunodeficiency virus [HIV], herpesviruses, syphilis, and systemic lupus erythematosus [SLE], among others), the lack of specificity of this finding limits its diagnostic utility. However, it is reasonable to ask whether the patient has noted frequent ulceration in the mouth or genitalia, as recurrent or severe ulcerations may narrow the diagnostic considerations. On the other hand, the focal nature of the pain inferior to the umbilicus suggests a discrete process in the abdomen or pelvis, such as an abscess, mass, or localized area of bowel inflammation. A plain abdominal film is likely to be low yield in this situation, so pursuing computed tomography is appropriate. Not all patients with focal abdominal pain require abdominal imaging, but in the context of weight loss and persistent symptoms for more than a week, imaging is prudent in this case.

The patient denied genital ulceration but did report painless oral ulcers over the preceding months. Laboratory evaluation revealed a white‐cell count of 1000/mm³, of which 6% were neutrophils, 5% were band forms, 36% were lymphocytes, and 47% were monocytes. The absolute neutrophil count was 110/mm³. Hemoglobin level was 10.2 g/dL with a mean corpuscular volume of 90 m³, and the platelet count was 151,000/mm³. Other results of laboratory studies were: sodium, 140 mmol/L; potassium, 3.8 mmol/L; chloride, 96 mmol/L; bicarbonate, 23 mmol/L; blood urea nitrogen, 13 mg/dL; creatinine, 0.4 mg/dL; lipase, 32 U/L (normal range, 13‐60); amylase, 73 U/L (normal range, 30‐110); albumin, 4.0 g/dL; aspartate aminotransferase, 779 U/L (normal range, 13‐35); alanine aminotransferase, 330 U/L (normal range, 7‐35); alkaline phosphatase, 510 U/L (normal range, 35‐104); and total bilirubin, 0.9 mg/dL (normal range, 0.1‐1.2). The lactate dehydrogenase level was 200 U/L (normal range, 135‐214). The corrected reticulocyte count was 1.6% (normal range, 0.3‐2.3), and haptoglobin was 190 mg/dL (normal range, 43‐212). A direct Coomb's test was positive. The erythrocyte sedimentation rate was 113 mm/hour (normal range, 1‐25). Urinalysis was normal without evidence of protein or blood.

Laboratory abnormalities include elevated transaminases and alkaline phosphatase, a markedly elevated erythrocyte sedimentation rate, and profound leukopenia with neutropenia. The patient is anemic, which may elevate the sedimentation rate but not typically to this degree. The patient is not febrile, but if she were to develop a fever, empiric antibiotics would be prudent. The normal albumin and bilirubin suggest that hepatic synthetic and excretory functions remain intact. Although the direct Coombs test is positive, the reticulocyte and lactate dehydrogenase levels argue against brisk hemolysis; this abnormality may simply be a marker of nonspecific immune activation. A variety of infections can cause neutropenia and liver enzyme abnormalities including parasites (malaria or leishmaniasis), viruses (cytomegalovirus or Epstein‐Barr virus [EBV]), tick‐borne bacterial infections (ehrlichiosis or rickettsial infection), and granulomatous infections (tuberculosis). Malignant infiltration of the reticuloendothelial system can also lead to cytopenias and liver enzyme abnormalities. Autoimmunity remains a consideration, as SLE may lead to cytopenias, oral ulcers, and nonspecific immune phenomena. Rather than ordering a large number of blood tests, I favor a targeted approach with abdominal computed tomography followed by biopsy of either the liver or bone marrow.

Chest radiography revealed no abnormalities. Computed tomography of the chest, abdomen, and pelvis with intravenous and oral contrast demonstrated concentric wall thickening of the transverse colon, but no evidence of obstruction or free air. The patient was treated with intravenous fluids, morphine, and cefepime. Bone marrow biopsy was performed, which demonstrated a hypercellular marrow with increased myeloid precursors and a left shift and megakaryocytic hyperplasia. Flow cytometry revealed no abnormally restricted clonal populations. A concerted search for an infectious etiology of the patient's neutropenia was unrevealing, including tests for HIV, cytomegalovirus, hepatitis A, hepatitis B, hepatitis C, Mycoplasma pneumoniae, EBV, and parvovirus B19.

I hope blood cultures were drawn prior to the initiation of antibiotics. Hypercellularity of the bone marrow in the context of leukopenia raises concern that white blood cells are being destroyed peripherally. Autoimmunity against neutrophils can be transiently induced by viruses such as HIV, hepatitis B, and EBV, but these infections have been excluded. Testing for antinuclear antibodies is reasonable. A normal‐sized spleen on the abdominal CT excludes hypersplenism. Colonic thickening can be associated with infection, ischemia, inflammatory bowel disease, and malignancy. The question is whether the colonic thickening is part of the same disease process causing the leukopenia and liver enzyme elevation or whether it represents a secondary infectious process in the setting of neutropenia (such as Clostridium difficile infection or typhlitis). Testing for stool pathogens (including ova and parasites) is certainly appropriate, and consideration of a colonoscopy with biopsy is reasonable, provided that appropriate antimicrobial coverage remains in place.

Blood cultures obtained prior to starting antibiotics were negative. The patient's abdominal pain improved, and she was discharged home to have close follow‐up with a hematologist. The results of her liver function tests improved, and her absolute neutrophil count was 230/mm³ at the time of discharge. Her neutropenia was believed to be secondary to peripheral destruction from a viral, drug‐mediated, or autoimmune process. Oxcarbazepine (Trileptal) was discontinued, as it was believed to be the medication most likely to be responsible. She returned to the hospital 3 days later with recurrence of her abdominal pain and diarrhea. She remained afebrile. Additional history revealed arthralgias over the previous 2 months, mild alopecia, and prior symptoms suggestive of Raynaud's phenomenon. Stool studies failed to establish an infectious etiology for the diarrhea, and her continued neutropenia responded appropriately to treatment with subcutaneous filgrastim. Colonoscopy could be performed only to the hepatic flexure and revealed no abnormalities. A serologic test for antinuclear antibodies was positive at a titer of 1:640 in a homogenous pattern, and a test for antineutrophil cytoplasmic antibodies was negative. Complement levels were normal, and tests for cryoglobulins, rapid plasma reagin, anticardiolipin antibody, lupus anticoagulant, rheumatoid factor, and antibodies to extractable nuclear antigens were all negative.

Raynaud's phenomenon is consistent with lupus. Double‐stranded DNA antibodies should be sent, although the urine did not demonstrate protein or an active sediment. Systemic sclerosis and the CREST syndrome is strongly associated with Raynaud's phenomenon and high‐titer ANA, but the patient does not have sclerodactyly, which is generally the earliest skin involvement. Autoimmune hepatitis is often associated with high‐titer ANA but does not fit this clinical picture. Given that the patient's presentation included segmental bowel wall thickening and a transient but marked liver enzyme elevation with AST predominance, I am concerned about vasculitis of the abdominal vasculature and would strongly consider a mesenteric angiogram.

To exclude mesenteric vasculitis, the patient underwent magnetic resonance angiography of the abdomen, the results of which were normal. A repeat test for antinuclear antibodies was positive at a titer of 1:2560 in a uniform pattern. A test for anti‐double‐stranded DNA was positive at 1370 U/mL. The patient was diagnosed with systemic lupus and probable lupus enteritis, and therapy with oral prednisone (10 mg daily) and hydroxychloroquine was initiated. She had prompt improvement in her abdominal pain, and was discharged home. Five months later she developed proteinuria and underwent a renal biopsy, which showed minor, nonspecific glomerular abnormalities, suggesting possible mild lupus nephritis. Eight months after her initial presentation, she remains free of abdominal pain and has regained the weight she had initially lost. Her oral ulcers have resolved, and her blood counts have normalized. Her serum creatinine has remained normal. She is now maintained on prednisone (15 mg daily), hydroxychloroquine, and mycophenolate mofetil.

COMMENTARY

A diagnosis of systemic lupus erythematosus (SLE) provided a unifying explanation for the patient's findings. Indeed, she manifested 4 of the 11 American College of Rheumatology criteria for systemic lupus (oral ulcers, leukopenia, positive anti‐DNA, and positive ANA), meeting criteria for a definite diagnosis of SLE. She additionally had multiple other features suggestive of lupus including Raynaud's phenomenon, arthralgias, alopecia, mild thrombocytopenia, and a positive Coombs' test (although the normal reticulocyte count, lactate dehydrogenase, and haptoglobin were most consistent with anemia of a chronic disease).

The protean manifestations of SLE can present significant diagnostic challenges. In this case, physicians were immediately drawn to the patient's acute abdominal pain and severe neutropenia and failed to recognize more subtle disease manifestations that may have aided in establishing a unifying diagnosis sooner. The initial history and review of systems did not disclose arthralgias, alopecia, or Raynaud's phenomenon. In an era of increasing use of hospitalists, which creates potential discontinuity between inpatient and outpatient physicians, a thorough history and review of systems may be particularly important in diagnosing acute manifestations of chronic systemic disease. Inpatient physicians may be overly focused on the small subset of acute complaints leading to hospitalization, without considering the larger constellation of symptoms that may facilitate accurate diagnosis. Our discussant quickly recognized the multisystem nature of the patient's illness and appropriately focused on infectious, neoplastic, and autoimmune categories of disease as being most likely. When infectious and neoplastic conditions were excluded with reasonable certainty, a directed serologic investigation for autoimmune disease was requested, culminating in a diagnosis of SLE.

Involvement of the skin as well as hematologic, renal, and musculoskeletal systems in SLE is commonly recognized, whereas gastrointestinal involvement is perceived to occur much less frequently. However, abdominal pain occurs in up to 40% of patients with lupus.14 Abdominal pain in lupus patients can arise from non‐lupus‐related conditions as well as lupus‐related entities, including serositis, mesenteric vasculitis with or without infarction, mesenteric thrombosis, pancreatitis, inflammatory bowel disease, and adverse medication effects including peptic ulcer disease. Abnormal liver chemistries, as seen in our patient, occur in 20%‐50% of patients with lupus and may be due to lupus hepatitis, concomitant autoimmune hepatitis, or medications including NSAIDs.5, 6 Oral ulcers and leukopenia are likewise common in SLE, with each seen in up to half of patients.4, 7, 8 Leukopenia in SLE may a result of neutropenia, lymphocytopenia, or both. However, severe neutropenia (ie, absolute count less than 500/L), as seen in our case, is more often a result of myelotoxicity from immunosuppressive therapy, rather than SLE itself.9

Lupus enteritis represents bowel microischemia from small‐vessel arteritis or venulitis that often is not evident on conventional mesenteric angiography.4, 10, 11 The reported prevalence of intestinal vasculitis in patients with SLE varies widely, depending on the characteristics of lupus patients sampled in individual studies. Intestinal vasculitis affects 0.2%‐0.5% of SLE patients in general,4, 12 whereas among SLE patients with active disease and an acute abdomen, vasculitis has been reported in up to 53% of patients.10 Antiphospholipid antibodies, antibodies to extractable nuclear antigens, the SLE Disease Activity Index, complement levels, erythrocyte sedimentation rate, C‐reactive protein, and anti‐double‐stranded DNA do not reliably differentiate lupus enteritis from acute abdominal pain due to other etiologies in patients with SLE.11 However, a concomitant drop in the white blood cell count at the onset of symptoms may be useful in distinguishing lupus enteritis from other causes of acute abdominal pain among lupus patients.11 Computed tomography findings consistent with lupus enteritis are nonspecific and include bowel‐wall thickening, submucosal edema (eg, target sign), dilatation of intestinal segments, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat.13 Colonoscopy may reveal areas of ischemia and ulceration, and biopsy can confirm intestinal vasculitis. However, intestinal involvement may be segmental, and pathologic confirmation may be difficult. Contrast enema, gallium scanning, and indium‐labeled white cell scanning may be useful, but lack specificity. No controlled trials to date have evaluated the optimal therapy for lupus enteritis, but pulsed methylprednisolone is often recommended.4 Cyclophosphamide, azathioprine, methotrexate, and cyclosporine have also been used as adjunctive agents. Patients may progress to intestinal infarction and perforation, which augurs a poor prognosis, and early surgical exploration should be considered in severely ill patients.10 Death may occur in more than two‐thirds of patients whose disease progresses to intestinal perforation.1

In summary, a multisystem disease such as SLE requires a comprehensive history, physical exam, and review of systems to establish a correct diagnosis. In our case, an extensive evaluation was necessary to exclude other etiologies of abdominal pain and systemic illness, particularly as infectious and neoplastic conditions occur far more often than lupus enteritis in the general population. However, profound laboratory abnormalities may have preoccupied the attention of treating physicians, leading them to overlook less obvious but important historical and physical findings suggestive of SLE. The cohesively abnormal forest may thus have been obscured by erratically abnormal individual trees. Gastrointestinal symptoms may be underrecognized in SLE. When these result for lupus enteritis, timely recognition may be lifesaving.

A 56‐year‐old woman from Colombia presented to the emergency department after 24 hours of abdominal pain. One week before, she had experienced similar pain that lasted for 4 hours and spontaneously resolved. She was nauseated but had no vomiting. She reported an unintentional 14‐pound weight loss over the preceding 3 weeks. She denied fever, chills, night sweats, diarrhea, constipation, dysuria, or jaundice.

In a middle‐aged woman with abdominal pain and nausea, diagnostic considerations include gallbladder disease, diseases of the bowel (such as a partial small‐bowel obstruction or inflammatory conditions), hepatic or pancreatic conditions, and nongastrointestinal ailments such as cardiac ischemia. Knowing the specific location of pain, its quality, precipitating factors, and accompanying systemic symptoms may help to narrow the diagnosis. The unintentional weight loss preceding the onset of pain may be an important clue because it suggests a systemic condition, and in a South American immigrantparticularly if she has traveled recentlyit is important to consider parasitic illnesses. The absence of fever makes some infections such as tuberculosis and malaria less likely. At this point, in addition to a thorough history and physical, laboratory tests should include a complete blood count (with quantification of eosinophils) and a metabolic panel with liver enzymes and albumin.

The patient described pain in the midline, just inferior to the umbilicus. The pain was constant, developed without any particular provocation, and was not related to meals or exertion. There were no constitutional symptoms aside from weight loss. She had a history of bipolar disorder, hypothyroidism, osteoarthritis, and chronic sinusitis and had previously undergone cholecystectomy and abdominal hysterectomy. She was taking levothyroxine, montelukast, bupropion, oxcarbazepine, fexofenadine, meloxicam, zolpidem, and, as needed, acetaminophen. She had recently completed a 10‐day course of levofloxacin for acute sinusitis. She had immigrated to the United States 10 years earlier and lived with her husband and daughter. She denied the use of tobacco, alcohol or illicit drugs. She had visited Colombia 6 months earlier but had no other recent travel history.

The history of cholecystectomy makes a biliary tract process unlikely. Its location reduces the likelihood of a hepatic or pancreatic process, but I would like to see the liver enzymes, especially given her recent acetaminophen use. The comorbid illnessesparticularly her bipolar disordermay be relevant because psychiatric illness might be associated with medication overuse or undisclosed toxic ingestions. For example, excess thyroxine might lead to weight loss while overuse of nonsteroidal anti‐inflammatory drugs such as meloxicam can cause intestinal ulceration, not only in the upper tract, but also in the colon. Undisclosed ingestions may also be associated with abdominal symptoms. Her surgical history makes adhesions with a secondary partial bowel obstruction possible. With no travel outside this country in the last 6 months, exotic infections are less likely. Finally, the recent course of levofloxacin may be relevant because many antibiotics are associated with nonspecific abdominal symptoms, and Clostridium difficile colitis occasionally presents without diarrhea.

The patient reported taking her medications as prescribed and denied ingesting other medications. On physical examination, she had a temperature of 98.9F, a pulse of 81 beats per minute, a blood pressure of 110/80 mm Hg, and a respiratory rate of 16 respirations per minute. She had a normal oxygen saturation while breathing ambient air. Her weight was 58 kg. There was no scleral icterus or jugular venous distension. She had a small painless ulcer involving the hard palate. Her lungs were clear to auscultation, and cardiac examination was normal. The abdomen was soft, bowel sounds were present, and there was moderate tenderness to palpation inferior to the umbilicus. There was no rebound or guarding, hepatosplenomegaly or other masses. There was no peripheral edema and no lymphadenopathy. Neurological examination was normal.

The oral ulcer may or may not be related to the clinical presentation because oral ulcers, whether painful or painless, are ubiquitous and may be isolated or may be associated with a wide range of infectious and noninfectious systemic diseases. Although some systemic causes of mucocutaneous ulcers are associated with weight loss (including Crohn's disease, Behcet's disease, celiac sprue, human immunodeficiency virus [HIV], herpesviruses, syphilis, and systemic lupus erythematosus [SLE], among others), the lack of specificity of this finding limits its diagnostic utility. However, it is reasonable to ask whether the patient has noted frequent ulceration in the mouth or genitalia, as recurrent or severe ulcerations may narrow the diagnostic considerations. On the other hand, the focal nature of the pain inferior to the umbilicus suggests a discrete process in the abdomen or pelvis, such as an abscess, mass, or localized area of bowel inflammation. A plain abdominal film is likely to be low yield in this situation, so pursuing computed tomography is appropriate. Not all patients with focal abdominal pain require abdominal imaging, but in the context of weight loss and persistent symptoms for more than a week, imaging is prudent in this case.

The patient denied genital ulceration but did report painless oral ulcers over the preceding months. Laboratory evaluation revealed a white‐cell count of 1000/mm³, of which 6% were neutrophils, 5% were band forms, 36% were lymphocytes, and 47% were monocytes. The absolute neutrophil count was 110/mm³. Hemoglobin level was 10.2 g/dL with a mean corpuscular volume of 90 m³, and the platelet count was 151,000/mm³. Other results of laboratory studies were: sodium, 140 mmol/L; potassium, 3.8 mmol/L; chloride, 96 mmol/L; bicarbonate, 23 mmol/L; blood urea nitrogen, 13 mg/dL; creatinine, 0.4 mg/dL; lipase, 32 U/L (normal range, 13‐60); amylase, 73 U/L (normal range, 30‐110); albumin, 4.0 g/dL; aspartate aminotransferase, 779 U/L (normal range, 13‐35); alanine aminotransferase, 330 U/L (normal range, 7‐35); alkaline phosphatase, 510 U/L (normal range, 35‐104); and total bilirubin, 0.9 mg/dL (normal range, 0.1‐1.2). The lactate dehydrogenase level was 200 U/L (normal range, 135‐214). The corrected reticulocyte count was 1.6% (normal range, 0.3‐2.3), and haptoglobin was 190 mg/dL (normal range, 43‐212). A direct Coomb's test was positive. The erythrocyte sedimentation rate was 113 mm/hour (normal range, 1‐25). Urinalysis was normal without evidence of protein or blood.

Laboratory abnormalities include elevated transaminases and alkaline phosphatase, a markedly elevated erythrocyte sedimentation rate, and profound leukopenia with neutropenia. The patient is anemic, which may elevate the sedimentation rate but not typically to this degree. The patient is not febrile, but if she were to develop a fever, empiric antibiotics would be prudent. The normal albumin and bilirubin suggest that hepatic synthetic and excretory functions remain intact. Although the direct Coombs test is positive, the reticulocyte and lactate dehydrogenase levels argue against brisk hemolysis; this abnormality may simply be a marker of nonspecific immune activation. A variety of infections can cause neutropenia and liver enzyme abnormalities including parasites (malaria or leishmaniasis), viruses (cytomegalovirus or Epstein‐Barr virus [EBV]), tick‐borne bacterial infections (ehrlichiosis or rickettsial infection), and granulomatous infections (tuberculosis). Malignant infiltration of the reticuloendothelial system can also lead to cytopenias and liver enzyme abnormalities. Autoimmunity remains a consideration, as SLE may lead to cytopenias, oral ulcers, and nonspecific immune phenomena. Rather than ordering a large number of blood tests, I favor a targeted approach with abdominal computed tomography followed by biopsy of either the liver or bone marrow.

Chest radiography revealed no abnormalities. Computed tomography of the chest, abdomen, and pelvis with intravenous and oral contrast demonstrated concentric wall thickening of the transverse colon, but no evidence of obstruction or free air. The patient was treated with intravenous fluids, morphine, and cefepime. Bone marrow biopsy was performed, which demonstrated a hypercellular marrow with increased myeloid precursors and a left shift and megakaryocytic hyperplasia. Flow cytometry revealed no abnormally restricted clonal populations. A concerted search for an infectious etiology of the patient's neutropenia was unrevealing, including tests for HIV, cytomegalovirus, hepatitis A, hepatitis B, hepatitis C, Mycoplasma pneumoniae, EBV, and parvovirus B19.

I hope blood cultures were drawn prior to the initiation of antibiotics. Hypercellularity of the bone marrow in the context of leukopenia raises concern that white blood cells are being destroyed peripherally. Autoimmunity against neutrophils can be transiently induced by viruses such as HIV, hepatitis B, and EBV, but these infections have been excluded. Testing for antinuclear antibodies is reasonable. A normal‐sized spleen on the abdominal CT excludes hypersplenism. Colonic thickening can be associated with infection, ischemia, inflammatory bowel disease, and malignancy. The question is whether the colonic thickening is part of the same disease process causing the leukopenia and liver enzyme elevation or whether it represents a secondary infectious process in the setting of neutropenia (such as Clostridium difficile infection or typhlitis). Testing for stool pathogens (including ova and parasites) is certainly appropriate, and consideration of a colonoscopy with biopsy is reasonable, provided that appropriate antimicrobial coverage remains in place.

Blood cultures obtained prior to starting antibiotics were negative. The patient's abdominal pain improved, and she was discharged home to have close follow‐up with a hematologist. The results of her liver function tests improved, and her absolute neutrophil count was 230/mm³ at the time of discharge. Her neutropenia was believed to be secondary to peripheral destruction from a viral, drug‐mediated, or autoimmune process. Oxcarbazepine (Trileptal) was discontinued, as it was believed to be the medication most likely to be responsible. She returned to the hospital 3 days later with recurrence of her abdominal pain and diarrhea. She remained afebrile. Additional history revealed arthralgias over the previous 2 months, mild alopecia, and prior symptoms suggestive of Raynaud's phenomenon. Stool studies failed to establish an infectious etiology for the diarrhea, and her continued neutropenia responded appropriately to treatment with subcutaneous filgrastim. Colonoscopy could be performed only to the hepatic flexure and revealed no abnormalities. A serologic test for antinuclear antibodies was positive at a titer of 1:640 in a homogenous pattern, and a test for antineutrophil cytoplasmic antibodies was negative. Complement levels were normal, and tests for cryoglobulins, rapid plasma reagin, anticardiolipin antibody, lupus anticoagulant, rheumatoid factor, and antibodies to extractable nuclear antigens were all negative.

Raynaud's phenomenon is consistent with lupus. Double‐stranded DNA antibodies should be sent, although the urine did not demonstrate protein or an active sediment. Systemic sclerosis and the CREST syndrome is strongly associated with Raynaud's phenomenon and high‐titer ANA, but the patient does not have sclerodactyly, which is generally the earliest skin involvement. Autoimmune hepatitis is often associated with high‐titer ANA but does not fit this clinical picture. Given that the patient's presentation included segmental bowel wall thickening and a transient but marked liver enzyme elevation with AST predominance, I am concerned about vasculitis of the abdominal vasculature and would strongly consider a mesenteric angiogram.

To exclude mesenteric vasculitis, the patient underwent magnetic resonance angiography of the abdomen, the results of which were normal. A repeat test for antinuclear antibodies was positive at a titer of 1:2560 in a uniform pattern. A test for anti‐double‐stranded DNA was positive at 1370 U/mL. The patient was diagnosed with systemic lupus and probable lupus enteritis, and therapy with oral prednisone (10 mg daily) and hydroxychloroquine was initiated. She had prompt improvement in her abdominal pain, and was discharged home. Five months later she developed proteinuria and underwent a renal biopsy, which showed minor, nonspecific glomerular abnormalities, suggesting possible mild lupus nephritis. Eight months after her initial presentation, she remains free of abdominal pain and has regained the weight she had initially lost. Her oral ulcers have resolved, and her blood counts have normalized. Her serum creatinine has remained normal. She is now maintained on prednisone (15 mg daily), hydroxychloroquine, and mycophenolate mofetil.

COMMENTARY

A diagnosis of systemic lupus erythematosus (SLE) provided a unifying explanation for the patient's findings. Indeed, she manifested 4 of the 11 American College of Rheumatology criteria for systemic lupus (oral ulcers, leukopenia, positive anti‐DNA, and positive ANA), meeting criteria for a definite diagnosis of SLE. She additionally had multiple other features suggestive of lupus including Raynaud's phenomenon, arthralgias, alopecia, mild thrombocytopenia, and a positive Coombs' test (although the normal reticulocyte count, lactate dehydrogenase, and haptoglobin were most consistent with anemia of a chronic disease).

The protean manifestations of SLE can present significant diagnostic challenges. In this case, physicians were immediately drawn to the patient's acute abdominal pain and severe neutropenia and failed to recognize more subtle disease manifestations that may have aided in establishing a unifying diagnosis sooner. The initial history and review of systems did not disclose arthralgias, alopecia, or Raynaud's phenomenon. In an era of increasing use of hospitalists, which creates potential discontinuity between inpatient and outpatient physicians, a thorough history and review of systems may be particularly important in diagnosing acute manifestations of chronic systemic disease. Inpatient physicians may be overly focused on the small subset of acute complaints leading to hospitalization, without considering the larger constellation of symptoms that may facilitate accurate diagnosis. Our discussant quickly recognized the multisystem nature of the patient's illness and appropriately focused on infectious, neoplastic, and autoimmune categories of disease as being most likely. When infectious and neoplastic conditions were excluded with reasonable certainty, a directed serologic investigation for autoimmune disease was requested, culminating in a diagnosis of SLE.

Involvement of the skin as well as hematologic, renal, and musculoskeletal systems in SLE is commonly recognized, whereas gastrointestinal involvement is perceived to occur much less frequently. However, abdominal pain occurs in up to 40% of patients with lupus.14 Abdominal pain in lupus patients can arise from non‐lupus‐related conditions as well as lupus‐related entities, including serositis, mesenteric vasculitis with or without infarction, mesenteric thrombosis, pancreatitis, inflammatory bowel disease, and adverse medication effects including peptic ulcer disease. Abnormal liver chemistries, as seen in our patient, occur in 20%‐50% of patients with lupus and may be due to lupus hepatitis, concomitant autoimmune hepatitis, or medications including NSAIDs.5, 6 Oral ulcers and leukopenia are likewise common in SLE, with each seen in up to half of patients.4, 7, 8 Leukopenia in SLE may a result of neutropenia, lymphocytopenia, or both. However, severe neutropenia (ie, absolute count less than 500/L), as seen in our case, is more often a result of myelotoxicity from immunosuppressive therapy, rather than SLE itself.9

Lupus enteritis represents bowel microischemia from small‐vessel arteritis or venulitis that often is not evident on conventional mesenteric angiography.4, 10, 11 The reported prevalence of intestinal vasculitis in patients with SLE varies widely, depending on the characteristics of lupus patients sampled in individual studies. Intestinal vasculitis affects 0.2%‐0.5% of SLE patients in general,4, 12 whereas among SLE patients with active disease and an acute abdomen, vasculitis has been reported in up to 53% of patients.10 Antiphospholipid antibodies, antibodies to extractable nuclear antigens, the SLE Disease Activity Index, complement levels, erythrocyte sedimentation rate, C‐reactive protein, and anti‐double‐stranded DNA do not reliably differentiate lupus enteritis from acute abdominal pain due to other etiologies in patients with SLE.11 However, a concomitant drop in the white blood cell count at the onset of symptoms may be useful in distinguishing lupus enteritis from other causes of acute abdominal pain among lupus patients.11 Computed tomography findings consistent with lupus enteritis are nonspecific and include bowel‐wall thickening, submucosal edema (eg, target sign), dilatation of intestinal segments, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat.13 Colonoscopy may reveal areas of ischemia and ulceration, and biopsy can confirm intestinal vasculitis. However, intestinal involvement may be segmental, and pathologic confirmation may be difficult. Contrast enema, gallium scanning, and indium‐labeled white cell scanning may be useful, but lack specificity. No controlled trials to date have evaluated the optimal therapy for lupus enteritis, but pulsed methylprednisolone is often recommended.4 Cyclophosphamide, azathioprine, methotrexate, and cyclosporine have also been used as adjunctive agents. Patients may progress to intestinal infarction and perforation, which augurs a poor prognosis, and early surgical exploration should be considered in severely ill patients.10 Death may occur in more than two‐thirds of patients whose disease progresses to intestinal perforation.1

In summary, a multisystem disease such as SLE requires a comprehensive history, physical exam, and review of systems to establish a correct diagnosis. In our case, an extensive evaluation was necessary to exclude other etiologies of abdominal pain and systemic illness, particularly as infectious and neoplastic conditions occur far more often than lupus enteritis in the general population. However, profound laboratory abnormalities may have preoccupied the attention of treating physicians, leading them to overlook less obvious but important historical and physical findings suggestive of SLE. The cohesively abnormal forest may thus have been obscured by erratically abnormal individual trees. Gastrointestinal symptoms may be underrecognized in SLE. When these result for lupus enteritis, timely recognition may be lifesaving.

A60‐year‐old man presented with agitation and a forehead mass (Figs. 1 and 2). His wife had noticed its rapid growth over several weeks and said he had recently become extremely confused and hostile. He had a history of smoking and exposures to silica and Agent Orange. His vitals and oxygen saturation were normal. He was cachectic but in no distress, and although he was uncooperative, his examination did not demonstrate an obvious neurological deficit. Routine electrolytes were within normal limits.

Figure 1

Figure 2

Noncontrast computed tomography of the skull revealed a 5.5 5.4 7.7cm frontal soft‐tissue density eroding his frontal bone and extending intracranially, with extensive displacement of both frontal lobes and invasion into his superior sagittal sinus (Fig. 3) and possible involvement of the brain parenchyma. A subsequent CT scan of the chest demonstrated a 7.8 7.9cm right mass in the lower lobe of the lung encasing the right pulmonary artery and 2 left renal masses.

Figure 3

Biopsy of the forehead mass demonstrated a necrotic, poorly differentiated carcinoma with focal clear‐cell features. Immunohistochemical staining was consistent with squamous cell carcinoma.

The forehead mass was painless, and the lung mass unresectable. His behavioral changes persisted and were attributed to the tumor compressing and possibly invading both frontal lobes. At his wife's request, he was discharged on dexamethasone with home hospice and died 2 weeks later.

Although there is little literature on the epidemiology of skull metastases, the most common malignancies to metastasize to the skull are breast and lung carcinomas. Others include prostate, thyroid, myeloma, and melanoma. Symptomatic metastases, including neurological findings, are unusual, except for tumors that metastasize to the skull base and cause cranial nerve deficits. Skeletal metastasis as the first manifestation of lung cancer occurs in about 2% of lung cancer patients and is a marker of poor prognosis. Received 2 November 2006; revision received 15 December 2006; accepted 16 January 2007.

A60‐year‐old man presented with agitation and a forehead mass (Figs. 1 and 2). His wife had noticed its rapid growth over several weeks and said he had recently become extremely confused and hostile. He had a history of smoking and exposures to silica and Agent Orange. His vitals and oxygen saturation were normal. He was cachectic but in no distress, and although he was uncooperative, his examination did not demonstrate an obvious neurological deficit. Routine electrolytes were within normal limits.

Figure 1

Figure 2

Noncontrast computed tomography of the skull revealed a 5.5 5.4 7.7cm frontal soft‐tissue density eroding his frontal bone and extending intracranially, with extensive displacement of both frontal lobes and invasion into his superior sagittal sinus (Fig. 3) and possible involvement of the brain parenchyma. A subsequent CT scan of the chest demonstrated a 7.8 7.9cm right mass in the lower lobe of the lung encasing the right pulmonary artery and 2 left renal masses.

Figure 3

Biopsy of the forehead mass demonstrated a necrotic, poorly differentiated carcinoma with focal clear‐cell features. Immunohistochemical staining was consistent with squamous cell carcinoma.

The forehead mass was painless, and the lung mass unresectable. His behavioral changes persisted and were attributed to the tumor compressing and possibly invading both frontal lobes. At his wife's request, he was discharged on dexamethasone with home hospice and died 2 weeks later.

Although there is little literature on the epidemiology of skull metastases, the most common malignancies to metastasize to the skull are breast and lung carcinomas. Others include prostate, thyroid, myeloma, and melanoma. Symptomatic metastases, including neurological findings, are unusual, except for tumors that metastasize to the skull base and cause cranial nerve deficits. Skeletal metastasis as the first manifestation of lung cancer occurs in about 2% of lung cancer patients and is a marker of poor prognosis. Received 2 November 2006; revision received 15 December 2006; accepted 16 January 2007.

A60‐year‐old man presented with agitation and a forehead mass (Figs. 1 and 2). His wife had noticed its rapid growth over several weeks and said he had recently become extremely confused and hostile. He had a history of smoking and exposures to silica and Agent Orange. His vitals and oxygen saturation were normal. He was cachectic but in no distress, and although he was uncooperative, his examination did not demonstrate an obvious neurological deficit. Routine electrolytes were within normal limits.

Figure 1

Figure 2

Noncontrast computed tomography of the skull revealed a 5.5 5.4 7.7cm frontal soft‐tissue density eroding his frontal bone and extending intracranially, with extensive displacement of both frontal lobes and invasion into his superior sagittal sinus (Fig. 3) and possible involvement of the brain parenchyma. A subsequent CT scan of the chest demonstrated a 7.8 7.9cm right mass in the lower lobe of the lung encasing the right pulmonary artery and 2 left renal masses.

Figure 3

Biopsy of the forehead mass demonstrated a necrotic, poorly differentiated carcinoma with focal clear‐cell features. Immunohistochemical staining was consistent with squamous cell carcinoma.

The forehead mass was painless, and the lung mass unresectable. His behavioral changes persisted and were attributed to the tumor compressing and possibly invading both frontal lobes. At his wife's request, he was discharged on dexamethasone with home hospice and died 2 weeks later.

Although there is little literature on the epidemiology of skull metastases, the most common malignancies to metastasize to the skull are breast and lung carcinomas. Others include prostate, thyroid, myeloma, and melanoma. Symptomatic metastases, including neurological findings, are unusual, except for tumors that metastasize to the skull base and cause cranial nerve deficits. Skeletal metastasis as the first manifestation of lung cancer occurs in about 2% of lung cancer patients and is a marker of poor prognosis. Received 2 November 2006; revision received 15 December 2006; accepted 16 January 2007.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Venous thromboembolism prophylaxis (VTE PX) has been identified as an area of primary importance to improve patient safety in research and clinical practice.13 Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common, often preventable life‐threatening condition for hospitalized patients.4 Up to half of patients admitted to the hospital are admitted from the emergency department (ED). Most of these patients are acutely ill with multiple risk factors for VTE. To reduce the incidence of VTE, these patients require routine evaluation to determine if thromboprophylaxis is needed, and when indicated, therapy should be started promptly on admission. The Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy outlines recommendations for VTE PX that reduce the development of DVT and PE.3 Despite there being effective VTE PX and the current focus on increasing its utilization to improve patient safety, VTE PX is underutilized. In particular, the subgroup of patients admitted from the ED, a group at high risk for VTE, has been neglected in the literature.

Our hypothesis was that VTE PX is underutilized in patients admitted through the ED. The specific objective of this study was to measure the rate at which hospitalized patients admitted though the ED received VTE PX.

METHODS

The study was conducted with the approval of and in accordance with the ethical standards of the Institutional Review Board of Baylor College of Medicine and Affiliated Hospitals. Prior to initiating chart review, passive consent was sought from physicians who were identified through the hospital medical records system as having admitted patients to this hospital through the ED in the preceding 6 months. Physicians were contacted twice in writing in a 1‐month period prior to study inception. Those who objected to their charts being reviewed were to notify the investigators. Otherwise, they were assumed to have consented to chart review. Fifteen percent of physicians declined chart review. Physicians were not informed of the particulars of the study, only that medication use in the ED was being evaluated.

This study was conducted at a private 900‐bed urban teaching hospital. The ED evaluates approximately 31,000 patients per year, predominantly a medical population. During the previous year, the ED had admitted roughly 30 patients per day, or 36% of all patients examined. Approximately 29% of admissions to this hospital (800/month) are admitted through the ED.

A convenience sample of every other hospital admission through the ED during 1 month was prospectively identified for inclusion in the study and chart review. Data were abstracted by a single reviewer on admission and at the time of discharge. The following data were collected: demographic characteristics, anticoagulant use or existing IVC filter, diagnoses, indications for full‐dose anticoagulation, indications for VTE PX (ie, immobilization, respiratory failure, congestive heart failure, limb trauma, surgery, or stroke), whether therapeutic anticoagulation or VTE PX was given, and date of initiation of this regimen, contraindications to anticoagulation, primary physician, and use of a standard order set. Patients were excluded if the attending physician declined chart review via the passive consent process. Other exclusion criteria were: receiving full‐dose anticoagulants before presentation to the ED, presence of an inferior vena cava (IVC) filter, indication for full‐dose anticoagulation (presented with DVT, PE, acute coronary syndrome), renal failure requiring hemodialysis (controversial risk for VTE59), length of stay (LOS) less than 2 days, and admission for psychiatric evaluation or treatment.

A modified Caprini's Risk Assessment Model for Surgical and Nonsurgical Patients was used to classify VTE risk.10 This tool assigns points to VTE risk factors so that risk and the need for VTE PX can be determined. For example, major surgery, central venous access, age older than 60 years, and bed rest for more than 72 hours are each assigned 2 points; higher‐risk factors such as hip or leg fractures or stroke are each assigned 5 points. This tool is generally in accord with the ACCP guidelines. Modifications made to this tool were to assign 3 points to patients in respiratory failure on ventilators and 5 points to patients who were critically ill on vasopressor medication. Decreased venous return associated with mechanical ventilation and peripheral vasoconstriction associated with the use of vasopressor medication justified the addition of these risk factors.11, 12 Patients were assigned to one of these risk categories: no risk (0 points), low risk (1 point), moderate risk (2 points), high risk (3‐4 points), or very high risk (5 or more points). As indicated by this risk assessment tool, those with moderate, high, or very high risk were considered in need of VTE PX.

Appropriate VTE PX was defined as any currently accepted medical (unfractionated heparin, low‐molecular‐weight heparin, or warfarin for orthopedic patients) or mechanical methods of VTE PX (sequential compression devices, and graduated compression stockings) for those in need and no VTE PX if none indicated. Aspirin, clopidogrel, or a combination of the 2 was not considered sufficient VTE PX.3 In addition, we established whether VTE PX as determined by the modified Caprini score was in line with ACCP guidelines, taking into account contraindications to anticoagulation. Preprinted order sets were divided into those that included VTE PX and those that did not. Order sets that included options for VTE PX were defined as standard order sets.

The primary objective of this study was to determine how frequently VTE PX was implemented in ED admissions. Secondary objectives were determining factors associated with correct VTE PX decision making and the proximity of orders for VTE PX to the time of admission.

RESULTS

Four hundred and fourteen charts of patient admissions were reviewed, of which 254 met the inclusion criteria. One‐hundred and sixty patients were excluded because they received full‐dose anticoagulation or had an existing IVC filter prior to admission (49 patients), received treatment with full‐dose anticoagulation in the ED (42 patients), had a LOS of less than 2 days (39 patients), or had end‐stage renal disease requiring hemodialysis (30 patients; Fig. 1).

Figure 1

Eighty percent of patients were admitted for medical problems, and 20% were admitted for surgery (Table 1). The most frequent admitting diagnoses were abdominal pain, congestive heart failure, chronic obstructive pulmonary disease, altered mental status, cerebral vascular accident, and pneumonia. The average patient had 5 comorbid conditions, the most frequently noted were hypertension, diabetes mellitus, anemia, urinary tract infections, and coronary artery disease. The principal admitting services were general medicine, pulmonary, cardiology, hematology‐oncology, neurology, surgery, and gastroenterology. Six patients died (2.4%), and 2 patients were diagnosed with pulmonary emboli (0.8%). The study group's average length of stay was 6.7 days (range 2‐52 days), 48.8% were male, and average age was 61 19.7 years. Overall, the correct VTE PX decision making occurred in 44.9% of patients admitted, including the 49 of 254 patients who did not require and did not receive VTE PX. Of the 254 patients, 201 (79%) had indications for VTE PX, 65 of whom (32.3%) received it (Table 2). For those receiving VTE PX, 78% of orders were written within the first day of hospitalization.

When the data were reanalyzed per ACCP guidelines using the modified Caprini's risk assessment tool, the results were consistent with the initial findings. Overall, 46% of all patients (116 of 254) received prophylaxis in compliance with ACCP guidelines. In this group, 52 of 116 patients (44.8%) did not require and did not receive VTE PX. Sixty‐four patients (32% of those with indications for prophylaxis) had indications for VTE PX, were in compliance with ACCP guidelines, and received the indicated prophylaxis (30 patients received mechanical prophylaxis, 19 patients received medical prophylaxis, and 15 patients received both medical and mechanical prophylaxis). The difference between the assessments was explained by high‐risk patients with no contraindications to medical prophylaxis who received only mechanical prophylaxis but required medical prophylaxis through ACCP guidelines. Note, the Caprini tool recommended medical prophylaxis for these high‐risk patients; however, our original application was simply to assess if prophylaxis was employed. In addition, several patients with a prolonged INR suggestive of bleeding risk or autoprophylaxis were reclassified as compliant and not needing prophylaxis.

Fifty‐five patients with indications for VTE prophylaxis had contraindications to medical prophylaxis: 44 had bleeding risk, 8 had spine injury or surgery, and 3 had brain metastases and thrombocytopenia. Twenty of the 55 patients (36%) received mechanical prophylaxis; they were considered in compliance with ACCP guidelines and were included in the appropriate decisions regarding VTE PX count. Prophylaxed patients at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of those prophylaxed patients who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

Standard order sets increased the likelihood of appropriate VTE PX. Increasing age and a primary cardiovascular diagnosis (chest pain, congestive heart failure, syncope/near‐syncope, chronic ischemic heart disease, sinus tachycardia) decreased the likelihood of VTE PX (Table 3). VTE PX was not significantly related to bed rest (OR = 1.46, P = .14). In 26 of the 254 patient admissions, standard order sets that included VTE PX were utilized. Of these 26 patients, 69.2% (18; P = .01) received appropriate VTE PX compared with the overall rate of 44.9% receiving appropriate VTE PX. The use of VTE PX was significantly associated with level of risk: from 0% in patients at no or low risk of VTE to 47% in patients at very high risk (P = .0001). This significance persisted when controlling for age greater than 60 years (Table 4).