While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.

Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.

Top Considerations

Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”

After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”

The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.

“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.

Biggest Challenges

One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.

These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.

Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.

In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.

Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.

Tailor the Summary

Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.

“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”

The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.

“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.

We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.

—Edward J. Merrens, MD

Back to Long-Term Care

The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:

1. Age 80 and older;
2. A history of depression;
3. Multiple chronic diseases;
4. Moderate-to-severe functional impairment;
5. Noncompliance with therapy;
6. Inadequate social supports;
7. Multiple hospitalizations in the previous six months;
8. Hospitalization in the last 30 days; and
9. Fair or poor self-rating of health.4

Patients who return to long-term care, therefore, need careful transfer of information.

Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).

At and After Discharge: Communicate with Patients and Families

Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5

Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.

The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.

Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8

Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.

Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9

Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.

Test Results and Follow-Up Studies

Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.

Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10

When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.

Follow-up Contact with Patients

Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.

Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13

In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.

Adverse Drug Events and Other Medication Issues

Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15

Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.

Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.

Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.

Top Considerations

Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”

After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”

The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.

“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.

Biggest Challenges

One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.

These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.

Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.

In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.

Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.

Tailor the Summary

Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.

“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”

The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.

“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.

We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.

—Edward J. Merrens, MD

Back to Long-Term Care

The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:

1. Age 80 and older;
2. A history of depression;
3. Multiple chronic diseases;
4. Moderate-to-severe functional impairment;
5. Noncompliance with therapy;
6. Inadequate social supports;
7. Multiple hospitalizations in the previous six months;
8. Hospitalization in the last 30 days; and
9. Fair or poor self-rating of health.4

Patients who return to long-term care, therefore, need careful transfer of information.

Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).

At and After Discharge: Communicate with Patients and Families

Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5

Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.

The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.

Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8

Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.

Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9

Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.

Test Results and Follow-Up Studies

Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.

Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10

When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.

Follow-up Contact with Patients

Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.

Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13

In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.

Adverse Drug Events and Other Medication Issues

Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15

Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.

Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.

Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.

Top Considerations

Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”

After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”

The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.

“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.

Biggest Challenges

One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.

These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.

Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.

In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.

Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.

Tailor the Summary

Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.

“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”

The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.

“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.

We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.

—Edward J. Merrens, MD

Back to Long-Term Care

The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:

1. Age 80 and older;
2. A history of depression;
3. Multiple chronic diseases;
4. Moderate-to-severe functional impairment;
5. Noncompliance with therapy;
6. Inadequate social supports;
7. Multiple hospitalizations in the previous six months;
8. Hospitalization in the last 30 days; and
9. Fair or poor self-rating of health.4

Patients who return to long-term care, therefore, need careful transfer of information.

Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).

At and After Discharge: Communicate with Patients and Families

Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5

Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.

The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.

Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8

Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.

Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9

Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.

Test Results and Follow-Up Studies

Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.

Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10

When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.

Follow-up Contact with Patients

Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.

Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13

In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.

Adverse Drug Events and Other Medication Issues

Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15

Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented.

Massachusetts’ lawmakers garnered huge headlines across the nation in April when the Democratic-dominated state legislature passed a health insurance reform bill nearly unanimously, and Republican Governor Mitt Romney signed the bill into law. This summer, health policy experts are hard at work implementing the first of many mandated stages of the legislation. Other states will watch Massachusetts in the next year as administrators hammer out details of the much-heralded bipartisan statute. Much remains to be done, however, and effects of the statute on patients, hospitals, and physicians remain unclear.

The hope is that the state can ensure nearly universal health insurance coverage for its estimated 500,000 citizens who currently have none. The Massachusetts statute aims to accomplish this feat by offering subsidized insurance coverage to those earning up to 300% of the federal poverty level (facilitated by a Medicaid waiver now being finalized between the state and CMS); assessing $295 per employee from businesses with 11 or more employees who do not provide coverage; and requiring purchase of affordable individual insurance products by those to whom such products are available.

Can the complex, market-driven compromise work? If all staged implementations go into effect as planned, will they be sustainable? Once in place, how might these reforms play out for the practice of hospital medicine? The Hospitalist recently solicited opinions from several hospitalists, physicians, a network president, and health policy experts to get some idea of what the future may hold for healthcare delivery in Massachusetts.

Key Features of the Legislation

As the number of uninsured Americans continues to grow, and reform at the federal level has stalled, many states have been working on their own plans to increase access to insurance and healthcare. The linchpin of individuals’ and businesses’ shared responsibility, health policy experts say, was key to the bipartisan support shown for the Massachusetts insurance reform bill. As of July 1, 2007, every citizen over 18 will be required to obtain health insurance. Businesses with 11 or more employees must pay $295 per employee if they do not offer coverage. (This provision was vetoed by Governor Romney when he signed the bill, but it was subsequently overridden by the legislature.)

The legislation—hundreds of pages long—stipulates an approximate two-year timeline for implementing all phases of the plan, and includes state tax penalties for individuals who don’t comply with the requirement to obtain insurance. The law also creates a state authority, The Commonwealth Health Insurance Connector, to set eligibility standards for subsidized policies, expand Medicaid enrollment, determine affordability guidelines, and approve of plans submitted by private insurers to be offered to consumers. It is anticipated that The Connector (its nickname) will act as a clearinghouse, linking individuals and small businesses with choices of affordable health plans paid for with pretax dollars.

Some of the features lauded by most—even critics—include expansion of Medicaid enrollment; policies with no to low premiums and no deductibles, on a sliding scale, for individuals and families earning up to 300% of the federal poverty line ($29,400 for individuals and $60,000 for families in the contiguous 48 states); and portability of the policies. In addition, young adults can remain covered through their parents’ policies until they become independent or reach age 25. Other specially designed low cost, limited coverage plans will be offered to young adults between ages 19 and 26.

In the press, the statute has been touted as providing “universal care,” but critics doubt that the coverage will be truly universal. For instance, they claim, based on U.S. Census data, that the number of uninsured in Massachusetts is closer to 714,000—not the 500,000 that resulted from bilingual telephone surveys used by those who drafted the bill. Those who espouse a single-payer solution to the insurance crisis, such as Physicians for a National Health Policy and Mass-Care (the statewide coalition of organizations that back single-payer healthcare), argue that mandating purchase of individual plans will shut many working families out of the market. Even administrators and physicians interviewed for this article admit that to generate affordable policies, insurers may have to limit networks and benefits. And increasing the number of insured citizens may have no effect on the rising tide of healthcare delivery costs. With so many unknowns, and a complicated administrative system to initiate, the task of fulfilling the statute’s mandate is daunting.

Where It Is Now

Reached in mid-July between meetings, Jon M. Kingsdale, PhD, newly appointed executive director of the Commonwealth Health Insurance Connector Authority, reported that his board had met five times since June 7. Included in its busy schedule: generating a plan of operations and a budget and hiring staff. The Connector also met its first legislative deadline, which was to develop and issue regulations and criteria by July 1, 2006, for contracting with health plans for the Commonwealth Care Health Insurance Program, or C-CHIP. This is the state-subsidized health plan for people earning up to 300% of the federal poverty line that will begin on October 1, 2006. Key features of C-CHIP and other components of the Massachusetts health reform include no premiums for those who earn less than 100% of the federal poverty line, increased coverage for children, and increased Medicaid reimbursement rates for providers (a good thing for hospitals). Premiums for those earning 100%-300% of the federal poverty line will be set according to a sliding scale, but none of the C-CHIP plans include deductibles. Funding for this plan will come from federal and state matching Medicaid funds made possible by a waiver currently being negotiated between Massachusetts and CMS. (Formal approval had not yet been granted by CMS as of July 21.)

As to the insurance products for those earning above 300% of the federal poverty level, Dr. Kingsdale says The Connector board will address affordability criteria once C-CHIP deadlines have been met. The legislation calls for The Connector to provide its seal of approval for plans that are offered and make determinations about continuing or withdrawing approval. After two years, the agency will formally evaluate the program and make recommendations for changes.

Reactions to the Plan

Joseph Li, MD, assistant professor of medicine at Harvard Medical School and director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston, admits that his excitement about the insurance statute is somewhat tempered. His personal opinion, which does not reflect his group’s or hospital’s opinion—is that he will “believe it when it’s truly enacted.”

Massachusetts has passed healthcare care reform bills in the past: Witness the 1988 legislation under Governor Michael Dukakis that was later repealed. Nevertheless, Dr. Li says, “I’m glad to see it happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.”

Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.

Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.

What’s “Affordable?”

The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”

People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.

“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].

“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”

Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.

Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”

Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”

Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”

I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.

—Joseph Li, MD

Some Likely Effects

For his hospitalist group at University of Massachusetts (UMass) Memorial Medical Center in Worcester, the new legislation “will not represent any new change in our mission or change in the composition of our typical patient panels,” says Glenn Allison, MD, chief of the Division of Hospital Medicine.

Hospitalists, in general, are accustomed to and adept at caring for unassigned patients included in the uncompensated pool, he notes, and at UMass, caring for these patients is a major mission of the hospital. Dr. Allison is hopeful that the legislation holds promise for bringing many previously marginalized and uninsured people into the healthcare system.

Thomas H. Lee, MD, MPH, network president of Partners HealthCare System, Inc, Boston, believes everyone in Massachusetts wants the healthcare reform to work. All stakeholders must “face reality,” he says, and realize that lowering the cost of healthcare is imperative. “It’s clear that the whole healthcare system must become more efficient. The imperative for that was present before this legislation was passed, and I’m not sure the pressures for that imperative are going to change qualitatively.”

One change Dr. Lee does foresee due to the legislation’s dependence on market reforms is that resulting insurance products will “spend a lot less money on patients than existing ones do. There are going to be a variety of pressures on doctors and hospitals to either be much more efficient or take less money for what they do,” he says. “Given that choice, most of us would rather become more efficient.”

Another consequence of affordable insurance products may be a narrowing of provider networks. And a narrow network product, says Sylvia C.W. McKean, MD, FACP, medical director of the BWH/Faulkner Hospitalist Service at Brigham and Women’s Hospital in Boston, “might result in a reduced number of patients going to tertiary care hospitals, which currently care for a large number of indigent patients.”

Even though standards of affordability and details of insurance products have yet to be generated by The Connector and insurers, Dr. Lee also believes that narrowing of benefits and networks will be one likely consequence of the legislation. This will entail some difficult choices about the range of services hospitals and physicians can offer. But, he says, “I think it’s worth doing painful, difficult stuff, and making painful, ugly choices in order for everyone to have necessary catastrophic care and to have access to basic preventive care. We should be willing to live with some of that ugly stuff because it will, in Massachusetts, at least, give us a chance of preventing the need for even uglier outcomes, which is, 10% of our population not having any coverage at all.”

Dr. Lee believes that hospitalists will be critical to the success of hospital efficiency. “To the extent that institutions can use hospitalists and other systems to become much more efficient and reduce readmissions, it’s going to mitigate the need for the narrowing of benefits and networks,” he says.

Now that these [formerly uninsured or underinsured] people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources.

—Glenn Allison, MD

Upshot for Hospitalists

Unknowns about the workability of and funding for the legislation abound. It’s not clear whether shifting costs to individuals (by mandating they purchase private insurance) and employers (via the $295 per employee fee) can bridge current deficits in compensation and care. Dr. Lee points out that “it’s still an open question of whether there is going to be enough money. But clearly, there are going to be insurance products that spend a lot less money on patients than existing ones do.”

Dr. Li does not believe these funding questions will affect the bottom line for his hospitalist group because their compensation is based on productivity, as measured by relative value units (RVUs).

The next 10 months or so leading up to the July 1, 2007, deadline for purchase of individual health insurance policies will be revealing for consumers and physicians alike. Although the devil will be in the details, Dr. Lee notes, “The big picture is not uncertain. We know there is going to be more transparency, more data, on quality and efficiency.”

That means that hospitals’ delivery of care will endure more scrutiny, and that pay for performance will become commonplace.

The influx of patients into the healthcare system, which legislators hope will be a consequence of greater access to care, will necessitate some consciousness-raising for hospitalists, Dr. Allison maintains. While hospitalists already work closely with other providers on the multidisciplinary team (social workers, case managers, and primary care physicians), they will have to strengthen those collaborations to ensure that patients don’t fall through the cracks. Community outreach may become part of the hospitalists’ job description.

For example, he explains, many preventive or follow-up services that are now being performed in the hospital because patients have no primary care physicians can now be referred to outpatient sites. “Now that these people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources,” he says.

Steering patients to community-based preventive services, such as early cardiac and cancer screenings, will fall to hospitalists, who will be “on the frontlines seeing these patients and referring them appropriately as they leave the hospital,” says Dr. Allison. Hospitalists and all providers will also be evaluated by how well they deliver culturally competent care—another mandate of the statute. To steer through these changes, hospitalists must become much more conscious, he says, of costs, communications, referrals, and resources. “That, as far as I can see, has not been a major emphasis of hospitalist literature or debate.”

A Role to Play

Dr. McKean and others contend that by virtue of their skill set and core mission, hospitalists will have much to contribute toward moderating the costs of healthcare. “The good news for hospitalists,” says Turnbull, “is that if we’re successful in providing health coverage to many people who are now uninsured and if that coverage is adequate there should be more people receiving primary and preventive care and services. This should prevent them from needing to go to the hospital in the first place. We should also be able to create more rational systems of care for people, so that when patients are in the hospital, they need to be there, and they can take full advantage of the talents and contributions that hospitalists make.”

Dr. Kingsdale agrees with the assessment that hospitalists will have a potentially significant role to play in improving the delivery, efficiency, and quality of care, as well as reducing medical errors. He hopes the new insurance products generated by companies will include financial incentives for hospitals and other providers who will be doing “the difficult work of changing their systems of care.”

“The healthcare system really has to improve,” asserts Dr. Lee. “In our organization, we say that we need both an industrial revolution and a cultural revolution, where we develop and use systems that reduce errors. There are electronic records and other industrial systems, and then there are human-ware systems, like hospitalists and disease management programs.”

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented. The April legislation “elevates the stakes for delivering effective, quality inpatient care,” says Dr. Allison. “I don’t want to over-inflate our importance, but I do think in a system where so many of our healthcare dollars are expended on the inpatient side, we’ve got to be extremely conscious of what we do.” This may mean shifting hospitalists’ implicit skills into the explicit realm, he says: “For instance, everyone talks about guidelines and how helpful they are, but we don’t do a good enough job when it comes to using them. We need to do better with vaccination, with discharge instructions, and with communicating and coordinating care.

“I think the care coordination piece is going to be the key to success,” concludes Dr. Allison. “I think we need to take what we do now, but do more of it, and do a better job of it. That is something that will make a tough job even tougher. But I think if we fail in this, the whole effort may collapse.” TH

Gretchen Henkel is coauthor of Marketing Your Clinical Practice—Ethically, Effectively, Economically.

Resources

1. Altman SH, Doonan M. “Can Massachusetts lead the way in health care reform?” N Engl J Med. 2006 May;354(20):2093-2095.
2. Steinbrook R. Health care reform in Massachusetts—a work in progress. N Engl J Med. 2006 May;354(20): 2095-2098.
3. The 184th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006, an act providing access to affordable, quality, accountable health care. Available at: www.mass.gov/legis/summary.pdf). Last accessed June 12, 2006.
4. Johnston PW, Turnbull NC. A bold insurance experiment. The Boston Globe. April 16, 2006. Available at: www.boston.com. Last accessed June 26, 2006.
5. McCormick D, Himmelstein DU, Woolhandler S, et al. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004 Feb 9;164(3):300-304.
6. “Massachusetts Health Reform Bill: A False Promise of Universal Coverage.” Statement by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD. Available at www.pnhp.org/news/2006/april/massachusetts_health.php. Last accessed June 26, 2006.

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented.

Massachusetts’ lawmakers garnered huge headlines across the nation in April when the Democratic-dominated state legislature passed a health insurance reform bill nearly unanimously, and Republican Governor Mitt Romney signed the bill into law. This summer, health policy experts are hard at work implementing the first of many mandated stages of the legislation. Other states will watch Massachusetts in the next year as administrators hammer out details of the much-heralded bipartisan statute. Much remains to be done, however, and effects of the statute on patients, hospitals, and physicians remain unclear.

The hope is that the state can ensure nearly universal health insurance coverage for its estimated 500,000 citizens who currently have none. The Massachusetts statute aims to accomplish this feat by offering subsidized insurance coverage to those earning up to 300% of the federal poverty level (facilitated by a Medicaid waiver now being finalized between the state and CMS); assessing $295 per employee from businesses with 11 or more employees who do not provide coverage; and requiring purchase of affordable individual insurance products by those to whom such products are available.

Can the complex, market-driven compromise work? If all staged implementations go into effect as planned, will they be sustainable? Once in place, how might these reforms play out for the practice of hospital medicine? The Hospitalist recently solicited opinions from several hospitalists, physicians, a network president, and health policy experts to get some idea of what the future may hold for healthcare delivery in Massachusetts.

Key Features of the Legislation

As the number of uninsured Americans continues to grow, and reform at the federal level has stalled, many states have been working on their own plans to increase access to insurance and healthcare. The linchpin of individuals’ and businesses’ shared responsibility, health policy experts say, was key to the bipartisan support shown for the Massachusetts insurance reform bill. As of July 1, 2007, every citizen over 18 will be required to obtain health insurance. Businesses with 11 or more employees must pay $295 per employee if they do not offer coverage. (This provision was vetoed by Governor Romney when he signed the bill, but it was subsequently overridden by the legislature.)

The legislation—hundreds of pages long—stipulates an approximate two-year timeline for implementing all phases of the plan, and includes state tax penalties for individuals who don’t comply with the requirement to obtain insurance. The law also creates a state authority, The Commonwealth Health Insurance Connector, to set eligibility standards for subsidized policies, expand Medicaid enrollment, determine affordability guidelines, and approve of plans submitted by private insurers to be offered to consumers. It is anticipated that The Connector (its nickname) will act as a clearinghouse, linking individuals and small businesses with choices of affordable health plans paid for with pretax dollars.

Some of the features lauded by most—even critics—include expansion of Medicaid enrollment; policies with no to low premiums and no deductibles, on a sliding scale, for individuals and families earning up to 300% of the federal poverty line ($29,400 for individuals and $60,000 for families in the contiguous 48 states); and portability of the policies. In addition, young adults can remain covered through their parents’ policies until they become independent or reach age 25. Other specially designed low cost, limited coverage plans will be offered to young adults between ages 19 and 26.

In the press, the statute has been touted as providing “universal care,” but critics doubt that the coverage will be truly universal. For instance, they claim, based on U.S. Census data, that the number of uninsured in Massachusetts is closer to 714,000—not the 500,000 that resulted from bilingual telephone surveys used by those who drafted the bill. Those who espouse a single-payer solution to the insurance crisis, such as Physicians for a National Health Policy and Mass-Care (the statewide coalition of organizations that back single-payer healthcare), argue that mandating purchase of individual plans will shut many working families out of the market. Even administrators and physicians interviewed for this article admit that to generate affordable policies, insurers may have to limit networks and benefits. And increasing the number of insured citizens may have no effect on the rising tide of healthcare delivery costs. With so many unknowns, and a complicated administrative system to initiate, the task of fulfilling the statute’s mandate is daunting.

Where It Is Now

Reached in mid-July between meetings, Jon M. Kingsdale, PhD, newly appointed executive director of the Commonwealth Health Insurance Connector Authority, reported that his board had met five times since June 7. Included in its busy schedule: generating a plan of operations and a budget and hiring staff. The Connector also met its first legislative deadline, which was to develop and issue regulations and criteria by July 1, 2006, for contracting with health plans for the Commonwealth Care Health Insurance Program, or C-CHIP. This is the state-subsidized health plan for people earning up to 300% of the federal poverty line that will begin on October 1, 2006. Key features of C-CHIP and other components of the Massachusetts health reform include no premiums for those who earn less than 100% of the federal poverty line, increased coverage for children, and increased Medicaid reimbursement rates for providers (a good thing for hospitals). Premiums for those earning 100%-300% of the federal poverty line will be set according to a sliding scale, but none of the C-CHIP plans include deductibles. Funding for this plan will come from federal and state matching Medicaid funds made possible by a waiver currently being negotiated between Massachusetts and CMS. (Formal approval had not yet been granted by CMS as of July 21.)

As to the insurance products for those earning above 300% of the federal poverty level, Dr. Kingsdale says The Connector board will address affordability criteria once C-CHIP deadlines have been met. The legislation calls for The Connector to provide its seal of approval for plans that are offered and make determinations about continuing or withdrawing approval. After two years, the agency will formally evaluate the program and make recommendations for changes.

Reactions to the Plan

Joseph Li, MD, assistant professor of medicine at Harvard Medical School and director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston, admits that his excitement about the insurance statute is somewhat tempered. His personal opinion, which does not reflect his group’s or hospital’s opinion—is that he will “believe it when it’s truly enacted.”

Massachusetts has passed healthcare care reform bills in the past: Witness the 1988 legislation under Governor Michael Dukakis that was later repealed. Nevertheless, Dr. Li says, “I’m glad to see it happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.”

Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.

Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.

What’s “Affordable?”

The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”

People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.

“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].

“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”

Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.

Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”

Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”

Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”

I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.

—Joseph Li, MD

Some Likely Effects

For his hospitalist group at University of Massachusetts (UMass) Memorial Medical Center in Worcester, the new legislation “will not represent any new change in our mission or change in the composition of our typical patient panels,” says Glenn Allison, MD, chief of the Division of Hospital Medicine.

Hospitalists, in general, are accustomed to and adept at caring for unassigned patients included in the uncompensated pool, he notes, and at UMass, caring for these patients is a major mission of the hospital. Dr. Allison is hopeful that the legislation holds promise for bringing many previously marginalized and uninsured people into the healthcare system.

Thomas H. Lee, MD, MPH, network president of Partners HealthCare System, Inc, Boston, believes everyone in Massachusetts wants the healthcare reform to work. All stakeholders must “face reality,” he says, and realize that lowering the cost of healthcare is imperative. “It’s clear that the whole healthcare system must become more efficient. The imperative for that was present before this legislation was passed, and I’m not sure the pressures for that imperative are going to change qualitatively.”

One change Dr. Lee does foresee due to the legislation’s dependence on market reforms is that resulting insurance products will “spend a lot less money on patients than existing ones do. There are going to be a variety of pressures on doctors and hospitals to either be much more efficient or take less money for what they do,” he says. “Given that choice, most of us would rather become more efficient.”

Another consequence of affordable insurance products may be a narrowing of provider networks. And a narrow network product, says Sylvia C.W. McKean, MD, FACP, medical director of the BWH/Faulkner Hospitalist Service at Brigham and Women’s Hospital in Boston, “might result in a reduced number of patients going to tertiary care hospitals, which currently care for a large number of indigent patients.”

Even though standards of affordability and details of insurance products have yet to be generated by The Connector and insurers, Dr. Lee also believes that narrowing of benefits and networks will be one likely consequence of the legislation. This will entail some difficult choices about the range of services hospitals and physicians can offer. But, he says, “I think it’s worth doing painful, difficult stuff, and making painful, ugly choices in order for everyone to have necessary catastrophic care and to have access to basic preventive care. We should be willing to live with some of that ugly stuff because it will, in Massachusetts, at least, give us a chance of preventing the need for even uglier outcomes, which is, 10% of our population not having any coverage at all.”

Dr. Lee believes that hospitalists will be critical to the success of hospital efficiency. “To the extent that institutions can use hospitalists and other systems to become much more efficient and reduce readmissions, it’s going to mitigate the need for the narrowing of benefits and networks,” he says.

Now that these [formerly uninsured or underinsured] people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources.

—Glenn Allison, MD

Upshot for Hospitalists

Unknowns about the workability of and funding for the legislation abound. It’s not clear whether shifting costs to individuals (by mandating they purchase private insurance) and employers (via the $295 per employee fee) can bridge current deficits in compensation and care. Dr. Lee points out that “it’s still an open question of whether there is going to be enough money. But clearly, there are going to be insurance products that spend a lot less money on patients than existing ones do.”

Dr. Li does not believe these funding questions will affect the bottom line for his hospitalist group because their compensation is based on productivity, as measured by relative value units (RVUs).

The next 10 months or so leading up to the July 1, 2007, deadline for purchase of individual health insurance policies will be revealing for consumers and physicians alike. Although the devil will be in the details, Dr. Lee notes, “The big picture is not uncertain. We know there is going to be more transparency, more data, on quality and efficiency.”

That means that hospitals’ delivery of care will endure more scrutiny, and that pay for performance will become commonplace.

The influx of patients into the healthcare system, which legislators hope will be a consequence of greater access to care, will necessitate some consciousness-raising for hospitalists, Dr. Allison maintains. While hospitalists already work closely with other providers on the multidisciplinary team (social workers, case managers, and primary care physicians), they will have to strengthen those collaborations to ensure that patients don’t fall through the cracks. Community outreach may become part of the hospitalists’ job description.

For example, he explains, many preventive or follow-up services that are now being performed in the hospital because patients have no primary care physicians can now be referred to outpatient sites. “Now that these people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources,” he says.

Steering patients to community-based preventive services, such as early cardiac and cancer screenings, will fall to hospitalists, who will be “on the frontlines seeing these patients and referring them appropriately as they leave the hospital,” says Dr. Allison. Hospitalists and all providers will also be evaluated by how well they deliver culturally competent care—another mandate of the statute. To steer through these changes, hospitalists must become much more conscious, he says, of costs, communications, referrals, and resources. “That, as far as I can see, has not been a major emphasis of hospitalist literature or debate.”

A Role to Play

Dr. McKean and others contend that by virtue of their skill set and core mission, hospitalists will have much to contribute toward moderating the costs of healthcare. “The good news for hospitalists,” says Turnbull, “is that if we’re successful in providing health coverage to many people who are now uninsured and if that coverage is adequate there should be more people receiving primary and preventive care and services. This should prevent them from needing to go to the hospital in the first place. We should also be able to create more rational systems of care for people, so that when patients are in the hospital, they need to be there, and they can take full advantage of the talents and contributions that hospitalists make.”

Dr. Kingsdale agrees with the assessment that hospitalists will have a potentially significant role to play in improving the delivery, efficiency, and quality of care, as well as reducing medical errors. He hopes the new insurance products generated by companies will include financial incentives for hospitals and other providers who will be doing “the difficult work of changing their systems of care.”

“The healthcare system really has to improve,” asserts Dr. Lee. “In our organization, we say that we need both an industrial revolution and a cultural revolution, where we develop and use systems that reduce errors. There are electronic records and other industrial systems, and then there are human-ware systems, like hospitalists and disease management programs.”

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented. The April legislation “elevates the stakes for delivering effective, quality inpatient care,” says Dr. Allison. “I don’t want to over-inflate our importance, but I do think in a system where so many of our healthcare dollars are expended on the inpatient side, we’ve got to be extremely conscious of what we do.” This may mean shifting hospitalists’ implicit skills into the explicit realm, he says: “For instance, everyone talks about guidelines and how helpful they are, but we don’t do a good enough job when it comes to using them. We need to do better with vaccination, with discharge instructions, and with communicating and coordinating care.

“I think the care coordination piece is going to be the key to success,” concludes Dr. Allison. “I think we need to take what we do now, but do more of it, and do a better job of it. That is something that will make a tough job even tougher. But I think if we fail in this, the whole effort may collapse.” TH

Gretchen Henkel is coauthor of Marketing Your Clinical Practice—Ethically, Effectively, Economically.

Resources

1. Altman SH, Doonan M. “Can Massachusetts lead the way in health care reform?” N Engl J Med. 2006 May;354(20):2093-2095.
2. Steinbrook R. Health care reform in Massachusetts—a work in progress. N Engl J Med. 2006 May;354(20): 2095-2098.
3. The 184th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006, an act providing access to affordable, quality, accountable health care. Available at: www.mass.gov/legis/summary.pdf). Last accessed June 12, 2006.
4. Johnston PW, Turnbull NC. A bold insurance experiment. The Boston Globe. April 16, 2006. Available at: www.boston.com. Last accessed June 26, 2006.
5. McCormick D, Himmelstein DU, Woolhandler S, et al. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004 Feb 9;164(3):300-304.
6. “Massachusetts Health Reform Bill: A False Promise of Universal Coverage.” Statement by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD. Available at www.pnhp.org/news/2006/april/massachusetts_health.php. Last accessed June 26, 2006.

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented.

Massachusetts’ lawmakers garnered huge headlines across the nation in April when the Democratic-dominated state legislature passed a health insurance reform bill nearly unanimously, and Republican Governor Mitt Romney signed the bill into law. This summer, health policy experts are hard at work implementing the first of many mandated stages of the legislation. Other states will watch Massachusetts in the next year as administrators hammer out details of the much-heralded bipartisan statute. Much remains to be done, however, and effects of the statute on patients, hospitals, and physicians remain unclear.

The hope is that the state can ensure nearly universal health insurance coverage for its estimated 500,000 citizens who currently have none. The Massachusetts statute aims to accomplish this feat by offering subsidized insurance coverage to those earning up to 300% of the federal poverty level (facilitated by a Medicaid waiver now being finalized between the state and CMS); assessing $295 per employee from businesses with 11 or more employees who do not provide coverage; and requiring purchase of affordable individual insurance products by those to whom such products are available.

Can the complex, market-driven compromise work? If all staged implementations go into effect as planned, will they be sustainable? Once in place, how might these reforms play out for the practice of hospital medicine? The Hospitalist recently solicited opinions from several hospitalists, physicians, a network president, and health policy experts to get some idea of what the future may hold for healthcare delivery in Massachusetts.

Key Features of the Legislation

As the number of uninsured Americans continues to grow, and reform at the federal level has stalled, many states have been working on their own plans to increase access to insurance and healthcare. The linchpin of individuals’ and businesses’ shared responsibility, health policy experts say, was key to the bipartisan support shown for the Massachusetts insurance reform bill. As of July 1, 2007, every citizen over 18 will be required to obtain health insurance. Businesses with 11 or more employees must pay $295 per employee if they do not offer coverage. (This provision was vetoed by Governor Romney when he signed the bill, but it was subsequently overridden by the legislature.)

The legislation—hundreds of pages long—stipulates an approximate two-year timeline for implementing all phases of the plan, and includes state tax penalties for individuals who don’t comply with the requirement to obtain insurance. The law also creates a state authority, The Commonwealth Health Insurance Connector, to set eligibility standards for subsidized policies, expand Medicaid enrollment, determine affordability guidelines, and approve of plans submitted by private insurers to be offered to consumers. It is anticipated that The Connector (its nickname) will act as a clearinghouse, linking individuals and small businesses with choices of affordable health plans paid for with pretax dollars.

Some of the features lauded by most—even critics—include expansion of Medicaid enrollment; policies with no to low premiums and no deductibles, on a sliding scale, for individuals and families earning up to 300% of the federal poverty line ($29,400 for individuals and $60,000 for families in the contiguous 48 states); and portability of the policies. In addition, young adults can remain covered through their parents’ policies until they become independent or reach age 25. Other specially designed low cost, limited coverage plans will be offered to young adults between ages 19 and 26.

In the press, the statute has been touted as providing “universal care,” but critics doubt that the coverage will be truly universal. For instance, they claim, based on U.S. Census data, that the number of uninsured in Massachusetts is closer to 714,000—not the 500,000 that resulted from bilingual telephone surveys used by those who drafted the bill. Those who espouse a single-payer solution to the insurance crisis, such as Physicians for a National Health Policy and Mass-Care (the statewide coalition of organizations that back single-payer healthcare), argue that mandating purchase of individual plans will shut many working families out of the market. Even administrators and physicians interviewed for this article admit that to generate affordable policies, insurers may have to limit networks and benefits. And increasing the number of insured citizens may have no effect on the rising tide of healthcare delivery costs. With so many unknowns, and a complicated administrative system to initiate, the task of fulfilling the statute’s mandate is daunting.

Where It Is Now

Reached in mid-July between meetings, Jon M. Kingsdale, PhD, newly appointed executive director of the Commonwealth Health Insurance Connector Authority, reported that his board had met five times since June 7. Included in its busy schedule: generating a plan of operations and a budget and hiring staff. The Connector also met its first legislative deadline, which was to develop and issue regulations and criteria by July 1, 2006, for contracting with health plans for the Commonwealth Care Health Insurance Program, or C-CHIP. This is the state-subsidized health plan for people earning up to 300% of the federal poverty line that will begin on October 1, 2006. Key features of C-CHIP and other components of the Massachusetts health reform include no premiums for those who earn less than 100% of the federal poverty line, increased coverage for children, and increased Medicaid reimbursement rates for providers (a good thing for hospitals). Premiums for those earning 100%-300% of the federal poverty line will be set according to a sliding scale, but none of the C-CHIP plans include deductibles. Funding for this plan will come from federal and state matching Medicaid funds made possible by a waiver currently being negotiated between Massachusetts and CMS. (Formal approval had not yet been granted by CMS as of July 21.)

As to the insurance products for those earning above 300% of the federal poverty level, Dr. Kingsdale says The Connector board will address affordability criteria once C-CHIP deadlines have been met. The legislation calls for The Connector to provide its seal of approval for plans that are offered and make determinations about continuing or withdrawing approval. After two years, the agency will formally evaluate the program and make recommendations for changes.

Reactions to the Plan

Joseph Li, MD, assistant professor of medicine at Harvard Medical School and director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston, admits that his excitement about the insurance statute is somewhat tempered. His personal opinion, which does not reflect his group’s or hospital’s opinion—is that he will “believe it when it’s truly enacted.”

Massachusetts has passed healthcare care reform bills in the past: Witness the 1988 legislation under Governor Michael Dukakis that was later repealed. Nevertheless, Dr. Li says, “I’m glad to see it happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.”

Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.

Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.

What’s “Affordable?”

The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”

People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.

“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].

“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”

Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.

Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”

Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”

Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”

I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.

—Joseph Li, MD

Some Likely Effects

For his hospitalist group at University of Massachusetts (UMass) Memorial Medical Center in Worcester, the new legislation “will not represent any new change in our mission or change in the composition of our typical patient panels,” says Glenn Allison, MD, chief of the Division of Hospital Medicine.

Hospitalists, in general, are accustomed to and adept at caring for unassigned patients included in the uncompensated pool, he notes, and at UMass, caring for these patients is a major mission of the hospital. Dr. Allison is hopeful that the legislation holds promise for bringing many previously marginalized and uninsured people into the healthcare system.

Thomas H. Lee, MD, MPH, network president of Partners HealthCare System, Inc, Boston, believes everyone in Massachusetts wants the healthcare reform to work. All stakeholders must “face reality,” he says, and realize that lowering the cost of healthcare is imperative. “It’s clear that the whole healthcare system must become more efficient. The imperative for that was present before this legislation was passed, and I’m not sure the pressures for that imperative are going to change qualitatively.”

One change Dr. Lee does foresee due to the legislation’s dependence on market reforms is that resulting insurance products will “spend a lot less money on patients than existing ones do. There are going to be a variety of pressures on doctors and hospitals to either be much more efficient or take less money for what they do,” he says. “Given that choice, most of us would rather become more efficient.”

Another consequence of affordable insurance products may be a narrowing of provider networks. And a narrow network product, says Sylvia C.W. McKean, MD, FACP, medical director of the BWH/Faulkner Hospitalist Service at Brigham and Women’s Hospital in Boston, “might result in a reduced number of patients going to tertiary care hospitals, which currently care for a large number of indigent patients.”

Even though standards of affordability and details of insurance products have yet to be generated by The Connector and insurers, Dr. Lee also believes that narrowing of benefits and networks will be one likely consequence of the legislation. This will entail some difficult choices about the range of services hospitals and physicians can offer. But, he says, “I think it’s worth doing painful, difficult stuff, and making painful, ugly choices in order for everyone to have necessary catastrophic care and to have access to basic preventive care. We should be willing to live with some of that ugly stuff because it will, in Massachusetts, at least, give us a chance of preventing the need for even uglier outcomes, which is, 10% of our population not having any coverage at all.”

Dr. Lee believes that hospitalists will be critical to the success of hospital efficiency. “To the extent that institutions can use hospitalists and other systems to become much more efficient and reduce readmissions, it’s going to mitigate the need for the narrowing of benefits and networks,” he says.

Now that these [formerly uninsured or underinsured] people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources.

—Glenn Allison, MD

Upshot for Hospitalists

Unknowns about the workability of and funding for the legislation abound. It’s not clear whether shifting costs to individuals (by mandating they purchase private insurance) and employers (via the $295 per employee fee) can bridge current deficits in compensation and care. Dr. Lee points out that “it’s still an open question of whether there is going to be enough money. But clearly, there are going to be insurance products that spend a lot less money on patients than existing ones do.”

Dr. Li does not believe these funding questions will affect the bottom line for his hospitalist group because their compensation is based on productivity, as measured by relative value units (RVUs).

The next 10 months or so leading up to the July 1, 2007, deadline for purchase of individual health insurance policies will be revealing for consumers and physicians alike. Although the devil will be in the details, Dr. Lee notes, “The big picture is not uncertain. We know there is going to be more transparency, more data, on quality and efficiency.”

That means that hospitals’ delivery of care will endure more scrutiny, and that pay for performance will become commonplace.

The influx of patients into the healthcare system, which legislators hope will be a consequence of greater access to care, will necessitate some consciousness-raising for hospitalists, Dr. Allison maintains. While hospitalists already work closely with other providers on the multidisciplinary team (social workers, case managers, and primary care physicians), they will have to strengthen those collaborations to ensure that patients don’t fall through the cracks. Community outreach may become part of the hospitalists’ job description.

For example, he explains, many preventive or follow-up services that are now being performed in the hospital because patients have no primary care physicians can now be referred to outpatient sites. “Now that these people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources,” he says.

Steering patients to community-based preventive services, such as early cardiac and cancer screenings, will fall to hospitalists, who will be “on the frontlines seeing these patients and referring them appropriately as they leave the hospital,” says Dr. Allison. Hospitalists and all providers will also be evaluated by how well they deliver culturally competent care—another mandate of the statute. To steer through these changes, hospitalists must become much more conscious, he says, of costs, communications, referrals, and resources. “That, as far as I can see, has not been a major emphasis of hospitalist literature or debate.”

A Role to Play

Dr. McKean and others contend that by virtue of their skill set and core mission, hospitalists will have much to contribute toward moderating the costs of healthcare. “The good news for hospitalists,” says Turnbull, “is that if we’re successful in providing health coverage to many people who are now uninsured and if that coverage is adequate there should be more people receiving primary and preventive care and services. This should prevent them from needing to go to the hospital in the first place. We should also be able to create more rational systems of care for people, so that when patients are in the hospital, they need to be there, and they can take full advantage of the talents and contributions that hospitalists make.”

Dr. Kingsdale agrees with the assessment that hospitalists will have a potentially significant role to play in improving the delivery, efficiency, and quality of care, as well as reducing medical errors. He hopes the new insurance products generated by companies will include financial incentives for hospitals and other providers who will be doing “the difficult work of changing their systems of care.”

“The healthcare system really has to improve,” asserts Dr. Lee. “In our organization, we say that we need both an industrial revolution and a cultural revolution, where we develop and use systems that reduce errors. There are electronic records and other industrial systems, and then there are human-ware systems, like hospitalists and disease management programs.”

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented. The April legislation “elevates the stakes for delivering effective, quality inpatient care,” says Dr. Allison. “I don’t want to over-inflate our importance, but I do think in a system where so many of our healthcare dollars are expended on the inpatient side, we’ve got to be extremely conscious of what we do.” This may mean shifting hospitalists’ implicit skills into the explicit realm, he says: “For instance, everyone talks about guidelines and how helpful they are, but we don’t do a good enough job when it comes to using them. We need to do better with vaccination, with discharge instructions, and with communicating and coordinating care.

“I think the care coordination piece is going to be the key to success,” concludes Dr. Allison. “I think we need to take what we do now, but do more of it, and do a better job of it. That is something that will make a tough job even tougher. But I think if we fail in this, the whole effort may collapse.” TH

Gretchen Henkel is coauthor of Marketing Your Clinical Practice—Ethically, Effectively, Economically.

Resources

1. Altman SH, Doonan M. “Can Massachusetts lead the way in health care reform?” N Engl J Med. 2006 May;354(20):2093-2095.
2. Steinbrook R. Health care reform in Massachusetts—a work in progress. N Engl J Med. 2006 May;354(20): 2095-2098.
3. The 184th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006, an act providing access to affordable, quality, accountable health care. Available at: www.mass.gov/legis/summary.pdf). Last accessed June 12, 2006.
4. Johnston PW, Turnbull NC. A bold insurance experiment. The Boston Globe. April 16, 2006. Available at: www.boston.com. Last accessed June 26, 2006.
5. McCormick D, Himmelstein DU, Woolhandler S, et al. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004 Feb 9;164(3):300-304.
6. “Massachusetts Health Reform Bill: A False Promise of Universal Coverage.” Statement by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD. Available at www.pnhp.org/news/2006/april/massachusetts_health.php. Last accessed June 26, 2006.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Co-Editors and Summit Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, and Raymond Borkowski, MD

Contents

Summit Faculty

Summit Program

IMPACT Consults

Does elevated blood pressure at the time of surgery increase perioperative cardiac risk?
Collin Kroen, MD

When is it appropriate to stop antiplatelet therapy in a patient with a drug-eluting stent prior to noncardiac surgery?
Anitha Rajamanickam, MD; Vaishali Singh, MD, MPH, MBA; and Ashish Aneja, MD

Should statins be discontinued preoperatively?
Paul J. Grant, MD, and Navin Kedia, DO

What is the appropriate means of perioperative risk assessment for patients with cirrhosis?
Brian Harte, MD

Who is at risk for developing acute renal failure after surgery?
Vesselin Dimov, MD; Ali Usmani, MD; Saira Noor, MD; and Ajay Kumar, MD

Why treat anemia in the preoperative period of joint replacement surgery with erythropoietin?
Ajay Kumar, MD, and Vesselin Dimov, MD

Obstructive sleep apnea: What to do in the surgical patient?
Roop Kaw, MD, and Joseph Golish, MD

What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery?
David V. Gugliotti, MD

Do hip fractures need to be repaired withing 24 hours of injury?
Christopher M. Whinney, MD

Is postoperative atrial fibrillation in patients undergoing noncardiothoracic surgery an important problem?
Ashish Aneja, MD, and Wassim H. Fares, MD

How can postoperative ileus be prevented and treated?
Vaishali Singh, MD, MPH, MBA

Abstracts

Oral Abstracts

Is discontinuation of antiplatelet therapy after 6 months safe in patients with drug-eluting stents undergoing noncardiac surgery?
Mihir Bakhru, Wael Saber, Daniel Brotman, Deepak Bhatt, Ashish Aneja, Katherina Tillan-Martinez, and Amir Jaffer

Initiating a preoperative cardiac risk assessment quality improvement program: The hurdles to changing traditional paradigms
Eric Hixson, Karl McCleary, Vikram Kashyap, Vaishali Singh, Brian Harte, Ashish Aneja, Brian Parker, Raymond Borkowski, Walter Maurer, Venkatesh Krishnamurthi, Sue Vitagliano, Jacqueline Matthews, Linda Vopat, Michael Henderson, and Amir Jaffer

Impact of a preoperative medical clinic on operating room cancellation rates in orthopedic surgery
Peter Kallas, Anjali Desai, and Jeanette Bauer

Poster Abstracts

Innovations in Perioperative Medicine

Abstract 1: Best safety practices to prevent postoperative myocardial infarction

Abstract 2: Blog web site as a new educational and promotional medium in perioperative medicine

Abstract 3: Development of a validated questionnaire: The satisfaction with general anesthesia scale

Abstract 4: Perioperative medicine and pain: A required advanced core clerkship for third-year medical students

Abstract 5: Optimal administration of perioperative antibiotics using system redesign

Abstract 6: Blood conservation protocol with erythropoietin in the preoperative period of joint replacement surgery

Abstract 7: Evolution of the nurse practitioner (NP) role in the Center for Preoperative Evaluation (CPE) at Brigham and Women's Hospital

Abstract 8: Development and implementation of a web site for the Center for Preoperative Evaluation (CPE)

Abstract 9: Patient education tool for the preoperative process and the role of the medical consultant

Abstract 10: The internal medicine perioperative assessment center: An innovation in the perioperative management of medical comorbidities at a comprehensive cancer center

Abstract 11: PAC collaborative practice model

Abstract 12: Development and implementation of beta-blocker recommendation

Abstract 13: Development of pre-procedure consult services

Perioperative Clinical Vignettes

Abstract 14: Isolated left bundle branch block in a patient undergoing elective noncardiac surgery

Abstract 15: Avoiding delirium

Abstract 16: Cardiac sarcoma—the role of multimodality cardiovascular imaging

Abstract 17: Asymptomatic bacteriuria before nonprosthetic joint surgery

Abstract 18: Negative T waves on the preoperative electrocardiogram—a cause for worry?

Abstract 19: Preoperative hypokalemia

Abstract 20: Preoperative evaluation can aid in the diagnosis of CAD and risk assessment and management

Research in Perioperative Medicine

Abstract 21: Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blockade

Abstract 22: Improving efficiency in a preoperative clinic

Abstract 23: Formalized preoperative assessment for noncardiac surgery at a large tertiary care medical center leads to higher rates of perioperative beta-blocker use

Abstract 24: Insulin errors in hospitalized patients

Abstract 25: A survey of perioperative beta-blockade at a comprehensive cancer center

Abstract 26: Risk factors for long-term mortality among heart failure patients after elective major noncardiac surgery

Index of Authors and Presenters

Supplement Co-Editors and Summit Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, and Raymond Borkowski, MD

Contents

Summit Faculty

Summit Program

IMPACT Consults

Does elevated blood pressure at the time of surgery increase perioperative cardiac risk?
Collin Kroen, MD

When is it appropriate to stop antiplatelet therapy in a patient with a drug-eluting stent prior to noncardiac surgery?
Anitha Rajamanickam, MD; Vaishali Singh, MD, MPH, MBA; and Ashish Aneja, MD

Should statins be discontinued preoperatively?
Paul J. Grant, MD, and Navin Kedia, DO

What is the appropriate means of perioperative risk assessment for patients with cirrhosis?
Brian Harte, MD

Who is at risk for developing acute renal failure after surgery?
Vesselin Dimov, MD; Ali Usmani, MD; Saira Noor, MD; and Ajay Kumar, MD

Why treat anemia in the preoperative period of joint replacement surgery with erythropoietin?
Ajay Kumar, MD, and Vesselin Dimov, MD

Obstructive sleep apnea: What to do in the surgical patient?
Roop Kaw, MD, and Joseph Golish, MD

What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery?
David V. Gugliotti, MD

Do hip fractures need to be repaired withing 24 hours of injury?
Christopher M. Whinney, MD

Is postoperative atrial fibrillation in patients undergoing noncardiothoracic surgery an important problem?
Ashish Aneja, MD, and Wassim H. Fares, MD

How can postoperative ileus be prevented and treated?
Vaishali Singh, MD, MPH, MBA

Abstracts

Oral Abstracts

Is discontinuation of antiplatelet therapy after 6 months safe in patients with drug-eluting stents undergoing noncardiac surgery?
Mihir Bakhru, Wael Saber, Daniel Brotman, Deepak Bhatt, Ashish Aneja, Katherina Tillan-Martinez, and Amir Jaffer

Initiating a preoperative cardiac risk assessment quality improvement program: The hurdles to changing traditional paradigms
Eric Hixson, Karl McCleary, Vikram Kashyap, Vaishali Singh, Brian Harte, Ashish Aneja, Brian Parker, Raymond Borkowski, Walter Maurer, Venkatesh Krishnamurthi, Sue Vitagliano, Jacqueline Matthews, Linda Vopat, Michael Henderson, and Amir Jaffer

Impact of a preoperative medical clinic on operating room cancellation rates in orthopedic surgery
Peter Kallas, Anjali Desai, and Jeanette Bauer

Poster Abstracts

Innovations in Perioperative Medicine

Abstract 1: Best safety practices to prevent postoperative myocardial infarction

Abstract 2: Blog web site as a new educational and promotional medium in perioperative medicine

Abstract 3: Development of a validated questionnaire: The satisfaction with general anesthesia scale

Abstract 4: Perioperative medicine and pain: A required advanced core clerkship for third-year medical students

Abstract 5: Optimal administration of perioperative antibiotics using system redesign

Abstract 6: Blood conservation protocol with erythropoietin in the preoperative period of joint replacement surgery

Abstract 7: Evolution of the nurse practitioner (NP) role in the Center for Preoperative Evaluation (CPE) at Brigham and Women's Hospital

Abstract 8: Development and implementation of a web site for the Center for Preoperative Evaluation (CPE)

Abstract 9: Patient education tool for the preoperative process and the role of the medical consultant

Abstract 10: The internal medicine perioperative assessment center: An innovation in the perioperative management of medical comorbidities at a comprehensive cancer center

Abstract 11: PAC collaborative practice model

Abstract 12: Development and implementation of beta-blocker recommendation

Abstract 13: Development of pre-procedure consult services

Perioperative Clinical Vignettes

Abstract 14: Isolated left bundle branch block in a patient undergoing elective noncardiac surgery

Abstract 15: Avoiding delirium

Abstract 16: Cardiac sarcoma—the role of multimodality cardiovascular imaging

Abstract 17: Asymptomatic bacteriuria before nonprosthetic joint surgery

Abstract 18: Negative T waves on the preoperative electrocardiogram—a cause for worry?

Abstract 19: Preoperative hypokalemia

Abstract 20: Preoperative evaluation can aid in the diagnosis of CAD and risk assessment and management

Research in Perioperative Medicine

Abstract 21: Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blockade

Abstract 22: Improving efficiency in a preoperative clinic

Abstract 23: Formalized preoperative assessment for noncardiac surgery at a large tertiary care medical center leads to higher rates of perioperative beta-blocker use

Abstract 24: Insulin errors in hospitalized patients

Abstract 25: A survey of perioperative beta-blockade at a comprehensive cancer center

Abstract 26: Risk factors for long-term mortality among heart failure patients after elective major noncardiac surgery

Index of Authors and Presenters

Supplement Co-Editors and Summit Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, and Raymond Borkowski, MD

Contents

Summit Faculty

Summit Program

IMPACT Consults

Does elevated blood pressure at the time of surgery increase perioperative cardiac risk?
Collin Kroen, MD

When is it appropriate to stop antiplatelet therapy in a patient with a drug-eluting stent prior to noncardiac surgery?
Anitha Rajamanickam, MD; Vaishali Singh, MD, MPH, MBA; and Ashish Aneja, MD

Should statins be discontinued preoperatively?
Paul J. Grant, MD, and Navin Kedia, DO

What is the appropriate means of perioperative risk assessment for patients with cirrhosis?
Brian Harte, MD

Who is at risk for developing acute renal failure after surgery?
Vesselin Dimov, MD; Ali Usmani, MD; Saira Noor, MD; and Ajay Kumar, MD

Why treat anemia in the preoperative period of joint replacement surgery with erythropoietin?
Ajay Kumar, MD, and Vesselin Dimov, MD

Obstructive sleep apnea: What to do in the surgical patient?
Roop Kaw, MD, and Joseph Golish, MD

What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery?
David V. Gugliotti, MD

Do hip fractures need to be repaired withing 24 hours of injury?
Christopher M. Whinney, MD

Is postoperative atrial fibrillation in patients undergoing noncardiothoracic surgery an important problem?
Ashish Aneja, MD, and Wassim H. Fares, MD

How can postoperative ileus be prevented and treated?
Vaishali Singh, MD, MPH, MBA

Abstracts

Oral Abstracts

Is discontinuation of antiplatelet therapy after 6 months safe in patients with drug-eluting stents undergoing noncardiac surgery?
Mihir Bakhru, Wael Saber, Daniel Brotman, Deepak Bhatt, Ashish Aneja, Katherina Tillan-Martinez, and Amir Jaffer

Initiating a preoperative cardiac risk assessment quality improvement program: The hurdles to changing traditional paradigms
Eric Hixson, Karl McCleary, Vikram Kashyap, Vaishali Singh, Brian Harte, Ashish Aneja, Brian Parker, Raymond Borkowski, Walter Maurer, Venkatesh Krishnamurthi, Sue Vitagliano, Jacqueline Matthews, Linda Vopat, Michael Henderson, and Amir Jaffer

Impact of a preoperative medical clinic on operating room cancellation rates in orthopedic surgery
Peter Kallas, Anjali Desai, and Jeanette Bauer

Poster Abstracts

Innovations in Perioperative Medicine

Abstract 1: Best safety practices to prevent postoperative myocardial infarction

Abstract 2: Blog web site as a new educational and promotional medium in perioperative medicine

Abstract 3: Development of a validated questionnaire: The satisfaction with general anesthesia scale

Abstract 4: Perioperative medicine and pain: A required advanced core clerkship for third-year medical students

Abstract 5: Optimal administration of perioperative antibiotics using system redesign

Abstract 6: Blood conservation protocol with erythropoietin in the preoperative period of joint replacement surgery

Abstract 7: Evolution of the nurse practitioner (NP) role in the Center for Preoperative Evaluation (CPE) at Brigham and Women's Hospital

Abstract 8: Development and implementation of a web site for the Center for Preoperative Evaluation (CPE)

Abstract 9: Patient education tool for the preoperative process and the role of the medical consultant

Abstract 10: The internal medicine perioperative assessment center: An innovation in the perioperative management of medical comorbidities at a comprehensive cancer center

Abstract 11: PAC collaborative practice model

Abstract 12: Development and implementation of beta-blocker recommendation

Abstract 13: Development of pre-procedure consult services

Perioperative Clinical Vignettes

Abstract 14: Isolated left bundle branch block in a patient undergoing elective noncardiac surgery

Abstract 15: Avoiding delirium

Abstract 16: Cardiac sarcoma—the role of multimodality cardiovascular imaging

Abstract 17: Asymptomatic bacteriuria before nonprosthetic joint surgery

Abstract 18: Negative T waves on the preoperative electrocardiogram—a cause for worry?

Abstract 19: Preoperative hypokalemia

Abstract 20: Preoperative evaluation can aid in the diagnosis of CAD and risk assessment and management

Research in Perioperative Medicine

Abstract 21: Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blockade

Abstract 22: Improving efficiency in a preoperative clinic

Abstract 23: Formalized preoperative assessment for noncardiac surgery at a large tertiary care medical center leads to higher rates of perioperative beta-blocker use

Abstract 24: Insulin errors in hospitalized patients

Abstract 25: A survey of perioperative beta-blockade at a comprehensive cancer center

Abstract 26: Risk factors for long-term mortality among heart failure patients after elective major noncardiac surgery

Index of Authors and Presenters