Q Can a perineoplasty be performed in the office as a minor procedure or does this require an operating room? Is there some way to bill for a simple repair in the office?

A CPT code 56810 (perineoplasty, repair of perineum, nonobstetric [separate procedure]) was valued under the Resource-Based Relative Value Scale as an inpatient procedure, and there are no practice expense relative value units added if the procedure is done in the office. That does not mean that a private payer will not pay for it in an office setting, but you would not be paid for the added expense of performing it in the office setting. Also keep in mind that the perineoplasty code, which has a 10-day global period, was valued based on hospital admission and subsequent hospital care as well, so if the payer denies it in the office setting it will be because you are not providing these services.

If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.

Q Can a perineoplasty be performed in the office as a minor procedure or does this require an operating room? Is there some way to bill for a simple repair in the office?

A CPT code 56810 (perineoplasty, repair of perineum, nonobstetric [separate procedure]) was valued under the Resource-Based Relative Value Scale as an inpatient procedure, and there are no practice expense relative value units added if the procedure is done in the office. That does not mean that a private payer will not pay for it in an office setting, but you would not be paid for the added expense of performing it in the office setting. Also keep in mind that the perineoplasty code, which has a 10-day global period, was valued based on hospital admission and subsequent hospital care as well, so if the payer denies it in the office setting it will be because you are not providing these services.

If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.

Q Can a perineoplasty be performed in the office as a minor procedure or does this require an operating room? Is there some way to bill for a simple repair in the office?

A CPT code 56810 (perineoplasty, repair of perineum, nonobstetric [separate procedure]) was valued under the Resource-Based Relative Value Scale as an inpatient procedure, and there are no practice expense relative value units added if the procedure is done in the office. That does not mean that a private payer will not pay for it in an office setting, but you would not be paid for the added expense of performing it in the office setting. Also keep in mind that the perineoplasty code, which has a 10-day global period, was valued based on hospital admission and subsequent hospital care as well, so if the payer denies it in the office setting it will be because you are not providing these services.

If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.

Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:

• correcting eating disorder behaviors and thoughts
• identifying and managing psychiatric comorbidity
• identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
• helping them achieve and maintain a healthy (but realistic) body weight.

Characteristics of BED and NES

BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).

Box1

Box2

Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,¹ whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).²

Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.³ Binge eating may be more common among African-Americans than Caucasians.⁴

Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.^5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.⁷

Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.⁸ Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.⁹

Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:

• >6-fold for major depression
• >8-fold for panic disorder
• >13-fold for borderline personality disorder, compared with obesity alone.¹⁰

Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.¹¹ They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.¹² Most NES patients view their nocturnal eating as shameful,¹³ and distress and guilt are among the diagnostic criteria for BED.

Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.¹⁴

Diagnosis and evaluation

Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.

 

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

• The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
• Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

• 46% with CBT
• 18.4% with behavioral weight loss
• 13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

• Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
• Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
• Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.

 

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

• 1,000 kcal/d liquid meal replacement
• 1,200 to 1,500 kcal/d diet of conventional food
• a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

• treatment availability and cost
• past treatment response
• patient preference
• psychiatric and medical comorbidities
• BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

• After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
• One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
• One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

• Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
• Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

• Anorexia and related eating disorders. www.anred.com (information about BED and NES).
• Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
  • Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
  • Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
• Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

Drug brand names

 

• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Orlistat • Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax

Disclosures

Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.

Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:

• correcting eating disorder behaviors and thoughts
• identifying and managing psychiatric comorbidity
• identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
• helping them achieve and maintain a healthy (but realistic) body weight.

Characteristics of BED and NES

BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).

Box1

Box2

Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,¹ whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).²

Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.³ Binge eating may be more common among African-Americans than Caucasians.⁴

Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.^5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.⁷

Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.⁸ Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.⁹

Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:

• >6-fold for major depression
• >8-fold for panic disorder
• >13-fold for borderline personality disorder, compared with obesity alone.¹⁰

Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.¹¹ They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.¹² Most NES patients view their nocturnal eating as shameful,¹³ and distress and guilt are among the diagnostic criteria for BED.

Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.¹⁴

Diagnosis and evaluation

Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.

 

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

• The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
• Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

• 46% with CBT
• 18.4% with behavioral weight loss
• 13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

• Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
• Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
• Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.

 

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

• 1,000 kcal/d liquid meal replacement
• 1,200 to 1,500 kcal/d diet of conventional food
• a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

• treatment availability and cost
• past treatment response
• patient preference
• psychiatric and medical comorbidities
• BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

• After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
• One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
• One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

• Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
• Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

• Anorexia and related eating disorders. www.anred.com (information about BED and NES).
• Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
  • Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
  • Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
• Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

Drug brand names

 

• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Orlistat • Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax

Disclosures

Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.

Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:

• correcting eating disorder behaviors and thoughts
• identifying and managing psychiatric comorbidity
• identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
• helping them achieve and maintain a healthy (but realistic) body weight.

Characteristics of BED and NES

BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).

Box1

Box2

Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,¹ whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).²

Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.³ Binge eating may be more common among African-Americans than Caucasians.⁴

Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.^5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.⁷

Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.⁸ Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.⁹

Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:

• >6-fold for major depression
• >8-fold for panic disorder
• >13-fold for borderline personality disorder, compared with obesity alone.¹⁰

Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.¹¹ They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.¹² Most NES patients view their nocturnal eating as shameful,¹³ and distress and guilt are among the diagnostic criteria for BED.

Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.¹⁴

Diagnosis and evaluation

Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.

 

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

• The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
• Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

• 46% with CBT
• 18.4% with behavioral weight loss
• 13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

• Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
• Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
• Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.

 

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

• 1,000 kcal/d liquid meal replacement
• 1,200 to 1,500 kcal/d diet of conventional food
• a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

• treatment availability and cost
• past treatment response
• patient preference
• psychiatric and medical comorbidities
• BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

• After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
• One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
• One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

• Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
• Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

• Anorexia and related eating disorders. www.anred.com (information about BED and NES).
• Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
  • Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
  • Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
• Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

Drug brand names

 

• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Orlistat • Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax

Disclosures

Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Beep, beep, beep, beep ... ,” the pager sounded. “What time is it?” asked Gregor S. His alarm clock flashed 7:42 a.m. He stumbled across the small apartment, grabbed a warm diet cola out of the grocery sack he had forgotten to unload in last night’s sleep-deprived state. The chicken was ruined, the bologna dubious. The whole bag ditched, save the six-pack.

Gregor went down the stairs two at a time. Mrs. Q with the arthritic boxer in 3G barely let him by, grumbling to herself about young folks today. No time for false pleasantries. He was late again. This would be the third time this month: his first month on staff as a hospitalist. He barely made the 7:52 bus, and was on ward 7 in a quarter of an hour.

At work—more Dr. S than Gregor—he hunted for an open computer. There were three on the ward. The head nurse hovered over a keyboard. Her shoulders were hunched and her body language said “Do not disturb.” Charting vitals or checking her stocks, it did not much matter. She was an immovable object, and he was no irresistible force.

The second keyboard was occupied by Heinrich W, the pharmacist. Dr. S had had a confrontation with the prickly pharmacist over an abbreviation two weeks ago and since then not a word had been spoken between them. Resigned, he approached the third keyboard.

Computer \JFSRVQ289476 was the worst in the entire hospital. The G key stuck and files seem to mysteriously disappear, but Dr. S had no other choice.

He tried to type in his password GREGORS/Hospital but the G button kept on sticking. He shook the keyboard and was ready to punch the monitor. He looked across the ward. The head nurse had left her computer. He got up to move there, but suddenly the G key became unfrozen and Dr. S typed the R and E, but the second G stuck again. He turned to move, but now a surgery resident had logged on to the other computer.

Amazingly, the G key yielded to Dr. S’ heartfelt entreaties, and Gregor signed on. His pager went off at that moment. Text message: Meeting with Committee R at 8:30, Mason Hall room 339. What was this all about? Committee R? What was Committee R? And where was Mason Hall? It was already 8:45 and he had not seen a patient yet. He could not reach the phone from his current position, so he left his seat and crossed the nurses’ station. He called his secretary, but only got her voice mail. He returned to the computer, but it had signed him off. His pager beeped for extension 5-44899. That was too many digits. All the hospital extensions had 5 digits.

He asked the ward clerk where Mason Hall was. She stared at him, chewing her gum and eyeing him like he was a giant cockroach. He turned to the pharmacist who had been watching the exchange, but he quickly turned his head back to the screen and doggedly ignored Dr. S.

Finally the head nurse came by. “Where is Mason Hall?” he pleaded with her. She shook her head at him. What kind of question was this? Why did he want to know where Mason Hall was? He told her about committee R.

 

“Go outside and look at the name of this building,” she snorted. This is Mason Hall. Dr. S shook his head; he’d never heard it called by that name. The pager again: Need admit orders for Mr. D. Who was this patient? He had heard of no admissions to his service today.

Dr. S ran down the stairs—no time to wait for the elevator. The staircase door on 3 was locked. He ran back up to 4, and that one was locked, too. He headed down the stairs. At the bottom a fire door was posted “Do Not Exit. Alarm Will Sound.” He pushed through. There was no alarm, and he found himself standing outside on the back of the building by the loading dock. His pager went off. The text message: Mr. D Needs Lab Orders. Mr. D? Who was this patient?

He made his way to the front of the building, sweating despite the cold temperature. His pager again alerted 67763—a number he recognized: the lab. The lab tech told him that “Mr. L’s K was 6.1.”

“Would the doctor please repeat this?” the tech asked. Dr. S tried to keep his temper. He had heard the result; why should he repeat it? It was policy per the tech. At too loud a voice he shouted, “Mr. L’s K is 6.1” and slammed the phone down in its cradle. He looked up and saw a crowd staring at him, including a small man with a notebook who peered at his ID badge and took notes. It was probably a HIPAA spy.

The lobby was crowded with families waiting for the one slow elevator. He would not risk the stairs again. He squeezed in between an oversize grandmother and a woman with three small but loud children. The doors began to close. Across the hall a man with packages was heading toward the elevator. “Let the doors close,” he prayed silently, “I couldn’t be any later.”

But the grandmother pressed the “door open” button. Floors 1 and 3 were pushed. The man was coming toward the doors. “Hurry up!” Dr. S pleaded to himself.

The man dropped his packages and then slowly picked them up. He walked to the doors and stood there. “I’m going down,” he said. The doors closed. On floor 1 the mother got off and a nurse got on. The nurse stared sullenly at Dr. S and then pressed the button for floor 2.

When the doors opened on 3, Dr. S nearly jumped off the elevator. He hustled down the hallway. Where was room 339? He followed the numbers 311, 313 down the long hallway. At the end of the hall was room 337. There was no room 339. His pager went off again Need orders for CT for Mr. D.

Finally he was back on the ward, logged in on his least favorite computer. On the other hand Mrs. J who had recently had an MI was doing better. He looked at her vitals, her labs. This was the way it was supposed to work. He wanted to start an ACE inhibitor. It was part of the protocol, but she had told him that ACE inhibitors had caused a cough in the past.

He pulled up her allergy list, NKDA. He put in the order for an ARB. A screen popped up: PATIENT POST-MI CONSIDER ACEI. He knew this, but had to use an ARB. He tried to put in the order again, but the pop-up returned. He pulled up the allergy list, and clicked “Update.” He tried to put in “ACEI-induced cough.” The system would not accept it. Then he tried “lisinopril-induced cough.” Again, didn’t work.

 

After four more attempts he gave up. He would order the ACEI, and if she coughed they would have to change it. He wrote the order to start low-dose ACEI. A screen popped up: Patient intolerant of ACEIs. Consider ARB. His pager went off again: Mr. D’s family waiting for results.

Dr. S checked his e-mail. There was a reminder not to miss his meeting with Committee R. There was a request from Nigeria from the deposed monarch’s widow for help regaining a vast sum of money, if he would only supply his bank account number; there was also an ad for “VIaGRow.” He searched the hospital database for Committee R, but before he could read the selection his pager went off again for extension 788988.

He called the hospital operator. The phone rang but no one picked up. His pager went off again: Sign discharge summary Mr. D.

The shift was finally over. Dr. S trudged down the hallway. At the nurses’ station there was a beautiful bouquet of flowers. The smell of anaerobes and melena was briefly replaced by the floral scent. As he walked off, the head nurse called to him. “Those are for you,” she mumbled.

“For me?” he wondered. At least someone appreciated his efforts. The annoyances and frustrations of the day seemed to melt away. He read the card: “Thanks for your excellent care. Mr. D and Family.” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Beep, beep, beep, beep ... ,” the pager sounded. “What time is it?” asked Gregor S. His alarm clock flashed 7:42 a.m. He stumbled across the small apartment, grabbed a warm diet cola out of the grocery sack he had forgotten to unload in last night’s sleep-deprived state. The chicken was ruined, the bologna dubious. The whole bag ditched, save the six-pack.

Gregor went down the stairs two at a time. Mrs. Q with the arthritic boxer in 3G barely let him by, grumbling to herself about young folks today. No time for false pleasantries. He was late again. This would be the third time this month: his first month on staff as a hospitalist. He barely made the 7:52 bus, and was on ward 7 in a quarter of an hour.

At work—more Dr. S than Gregor—he hunted for an open computer. There were three on the ward. The head nurse hovered over a keyboard. Her shoulders were hunched and her body language said “Do not disturb.” Charting vitals or checking her stocks, it did not much matter. She was an immovable object, and he was no irresistible force.

The second keyboard was occupied by Heinrich W, the pharmacist. Dr. S had had a confrontation with the prickly pharmacist over an abbreviation two weeks ago and since then not a word had been spoken between them. Resigned, he approached the third keyboard.

Computer \JFSRVQ289476 was the worst in the entire hospital. The G key stuck and files seem to mysteriously disappear, but Dr. S had no other choice.

He tried to type in his password GREGORS/Hospital but the G button kept on sticking. He shook the keyboard and was ready to punch the monitor. He looked across the ward. The head nurse had left her computer. He got up to move there, but suddenly the G key became unfrozen and Dr. S typed the R and E, but the second G stuck again. He turned to move, but now a surgery resident had logged on to the other computer.

Amazingly, the G key yielded to Dr. S’ heartfelt entreaties, and Gregor signed on. His pager went off at that moment. Text message: Meeting with Committee R at 8:30, Mason Hall room 339. What was this all about? Committee R? What was Committee R? And where was Mason Hall? It was already 8:45 and he had not seen a patient yet. He could not reach the phone from his current position, so he left his seat and crossed the nurses’ station. He called his secretary, but only got her voice mail. He returned to the computer, but it had signed him off. His pager beeped for extension 5-44899. That was too many digits. All the hospital extensions had 5 digits.

He asked the ward clerk where Mason Hall was. She stared at him, chewing her gum and eyeing him like he was a giant cockroach. He turned to the pharmacist who had been watching the exchange, but he quickly turned his head back to the screen and doggedly ignored Dr. S.

Finally the head nurse came by. “Where is Mason Hall?” he pleaded with her. She shook her head at him. What kind of question was this? Why did he want to know where Mason Hall was? He told her about committee R.

 

“Go outside and look at the name of this building,” she snorted. This is Mason Hall. Dr. S shook his head; he’d never heard it called by that name. The pager again: Need admit orders for Mr. D. Who was this patient? He had heard of no admissions to his service today.

Dr. S ran down the stairs—no time to wait for the elevator. The staircase door on 3 was locked. He ran back up to 4, and that one was locked, too. He headed down the stairs. At the bottom a fire door was posted “Do Not Exit. Alarm Will Sound.” He pushed through. There was no alarm, and he found himself standing outside on the back of the building by the loading dock. His pager went off. The text message: Mr. D Needs Lab Orders. Mr. D? Who was this patient?

He made his way to the front of the building, sweating despite the cold temperature. His pager again alerted 67763—a number he recognized: the lab. The lab tech told him that “Mr. L’s K was 6.1.”

“Would the doctor please repeat this?” the tech asked. Dr. S tried to keep his temper. He had heard the result; why should he repeat it? It was policy per the tech. At too loud a voice he shouted, “Mr. L’s K is 6.1” and slammed the phone down in its cradle. He looked up and saw a crowd staring at him, including a small man with a notebook who peered at his ID badge and took notes. It was probably a HIPAA spy.

The lobby was crowded with families waiting for the one slow elevator. He would not risk the stairs again. He squeezed in between an oversize grandmother and a woman with three small but loud children. The doors began to close. Across the hall a man with packages was heading toward the elevator. “Let the doors close,” he prayed silently, “I couldn’t be any later.”

But the grandmother pressed the “door open” button. Floors 1 and 3 were pushed. The man was coming toward the doors. “Hurry up!” Dr. S pleaded to himself.

The man dropped his packages and then slowly picked them up. He walked to the doors and stood there. “I’m going down,” he said. The doors closed. On floor 1 the mother got off and a nurse got on. The nurse stared sullenly at Dr. S and then pressed the button for floor 2.

When the doors opened on 3, Dr. S nearly jumped off the elevator. He hustled down the hallway. Where was room 339? He followed the numbers 311, 313 down the long hallway. At the end of the hall was room 337. There was no room 339. His pager went off again Need orders for CT for Mr. D.

Finally he was back on the ward, logged in on his least favorite computer. On the other hand Mrs. J who had recently had an MI was doing better. He looked at her vitals, her labs. This was the way it was supposed to work. He wanted to start an ACE inhibitor. It was part of the protocol, but she had told him that ACE inhibitors had caused a cough in the past.

He pulled up her allergy list, NKDA. He put in the order for an ARB. A screen popped up: PATIENT POST-MI CONSIDER ACEI. He knew this, but had to use an ARB. He tried to put in the order again, but the pop-up returned. He pulled up the allergy list, and clicked “Update.” He tried to put in “ACEI-induced cough.” The system would not accept it. Then he tried “lisinopril-induced cough.” Again, didn’t work.

 

After four more attempts he gave up. He would order the ACEI, and if she coughed they would have to change it. He wrote the order to start low-dose ACEI. A screen popped up: Patient intolerant of ACEIs. Consider ARB. His pager went off again: Mr. D’s family waiting for results.

Dr. S checked his e-mail. There was a reminder not to miss his meeting with Committee R. There was a request from Nigeria from the deposed monarch’s widow for help regaining a vast sum of money, if he would only supply his bank account number; there was also an ad for “VIaGRow.” He searched the hospital database for Committee R, but before he could read the selection his pager went off again for extension 788988.

He called the hospital operator. The phone rang but no one picked up. His pager went off again: Sign discharge summary Mr. D.

The shift was finally over. Dr. S trudged down the hallway. At the nurses’ station there was a beautiful bouquet of flowers. The smell of anaerobes and melena was briefly replaced by the floral scent. As he walked off, the head nurse called to him. “Those are for you,” she mumbled.

“For me?” he wondered. At least someone appreciated his efforts. The annoyances and frustrations of the day seemed to melt away. He read the card: “Thanks for your excellent care. Mr. D and Family.” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Beep, beep, beep, beep ... ,” the pager sounded. “What time is it?” asked Gregor S. His alarm clock flashed 7:42 a.m. He stumbled across the small apartment, grabbed a warm diet cola out of the grocery sack he had forgotten to unload in last night’s sleep-deprived state. The chicken was ruined, the bologna dubious. The whole bag ditched, save the six-pack.

Gregor went down the stairs two at a time. Mrs. Q with the arthritic boxer in 3G barely let him by, grumbling to herself about young folks today. No time for false pleasantries. He was late again. This would be the third time this month: his first month on staff as a hospitalist. He barely made the 7:52 bus, and was on ward 7 in a quarter of an hour.

At work—more Dr. S than Gregor—he hunted for an open computer. There were three on the ward. The head nurse hovered over a keyboard. Her shoulders were hunched and her body language said “Do not disturb.” Charting vitals or checking her stocks, it did not much matter. She was an immovable object, and he was no irresistible force.

The second keyboard was occupied by Heinrich W, the pharmacist. Dr. S had had a confrontation with the prickly pharmacist over an abbreviation two weeks ago and since then not a word had been spoken between them. Resigned, he approached the third keyboard.

Computer \JFSRVQ289476 was the worst in the entire hospital. The G key stuck and files seem to mysteriously disappear, but Dr. S had no other choice.

He tried to type in his password GREGORS/Hospital but the G button kept on sticking. He shook the keyboard and was ready to punch the monitor. He looked across the ward. The head nurse had left her computer. He got up to move there, but suddenly the G key became unfrozen and Dr. S typed the R and E, but the second G stuck again. He turned to move, but now a surgery resident had logged on to the other computer.

Amazingly, the G key yielded to Dr. S’ heartfelt entreaties, and Gregor signed on. His pager went off at that moment. Text message: Meeting with Committee R at 8:30, Mason Hall room 339. What was this all about? Committee R? What was Committee R? And where was Mason Hall? It was already 8:45 and he had not seen a patient yet. He could not reach the phone from his current position, so he left his seat and crossed the nurses’ station. He called his secretary, but only got her voice mail. He returned to the computer, but it had signed him off. His pager beeped for extension 5-44899. That was too many digits. All the hospital extensions had 5 digits.

He asked the ward clerk where Mason Hall was. She stared at him, chewing her gum and eyeing him like he was a giant cockroach. He turned to the pharmacist who had been watching the exchange, but he quickly turned his head back to the screen and doggedly ignored Dr. S.

Finally the head nurse came by. “Where is Mason Hall?” he pleaded with her. She shook her head at him. What kind of question was this? Why did he want to know where Mason Hall was? He told her about committee R.

 

“Go outside and look at the name of this building,” she snorted. This is Mason Hall. Dr. S shook his head; he’d never heard it called by that name. The pager again: Need admit orders for Mr. D. Who was this patient? He had heard of no admissions to his service today.

Dr. S ran down the stairs—no time to wait for the elevator. The staircase door on 3 was locked. He ran back up to 4, and that one was locked, too. He headed down the stairs. At the bottom a fire door was posted “Do Not Exit. Alarm Will Sound.” He pushed through. There was no alarm, and he found himself standing outside on the back of the building by the loading dock. His pager went off. The text message: Mr. D Needs Lab Orders. Mr. D? Who was this patient?

He made his way to the front of the building, sweating despite the cold temperature. His pager again alerted 67763—a number he recognized: the lab. The lab tech told him that “Mr. L’s K was 6.1.”

“Would the doctor please repeat this?” the tech asked. Dr. S tried to keep his temper. He had heard the result; why should he repeat it? It was policy per the tech. At too loud a voice he shouted, “Mr. L’s K is 6.1” and slammed the phone down in its cradle. He looked up and saw a crowd staring at him, including a small man with a notebook who peered at his ID badge and took notes. It was probably a HIPAA spy.

The lobby was crowded with families waiting for the one slow elevator. He would not risk the stairs again. He squeezed in between an oversize grandmother and a woman with three small but loud children. The doors began to close. Across the hall a man with packages was heading toward the elevator. “Let the doors close,” he prayed silently, “I couldn’t be any later.”

But the grandmother pressed the “door open” button. Floors 1 and 3 were pushed. The man was coming toward the doors. “Hurry up!” Dr. S pleaded to himself.

The man dropped his packages and then slowly picked them up. He walked to the doors and stood there. “I’m going down,” he said. The doors closed. On floor 1 the mother got off and a nurse got on. The nurse stared sullenly at Dr. S and then pressed the button for floor 2.

When the doors opened on 3, Dr. S nearly jumped off the elevator. He hustled down the hallway. Where was room 339? He followed the numbers 311, 313 down the long hallway. At the end of the hall was room 337. There was no room 339. His pager went off again Need orders for CT for Mr. D.

Finally he was back on the ward, logged in on his least favorite computer. On the other hand Mrs. J who had recently had an MI was doing better. He looked at her vitals, her labs. This was the way it was supposed to work. He wanted to start an ACE inhibitor. It was part of the protocol, but she had told him that ACE inhibitors had caused a cough in the past.

He pulled up her allergy list, NKDA. He put in the order for an ARB. A screen popped up: PATIENT POST-MI CONSIDER ACEI. He knew this, but had to use an ARB. He tried to put in the order again, but the pop-up returned. He pulled up the allergy list, and clicked “Update.” He tried to put in “ACEI-induced cough.” The system would not accept it. Then he tried “lisinopril-induced cough.” Again, didn’t work.

 

After four more attempts he gave up. He would order the ACEI, and if she coughed they would have to change it. He wrote the order to start low-dose ACEI. A screen popped up: Patient intolerant of ACEIs. Consider ARB. His pager went off again: Mr. D’s family waiting for results.

Dr. S checked his e-mail. There was a reminder not to miss his meeting with Committee R. There was a request from Nigeria from the deposed monarch’s widow for help regaining a vast sum of money, if he would only supply his bank account number; there was also an ad for “VIaGRow.” He searched the hospital database for Committee R, but before he could read the selection his pager went off again for extension 788988.

He called the hospital operator. The phone rang but no one picked up. His pager went off again: Sign discharge summary Mr. D.

The shift was finally over. Dr. S trudged down the hallway. At the nurses’ station there was a beautiful bouquet of flowers. The smell of anaerobes and melena was briefly replaced by the floral scent. As he walked off, the head nurse called to him. “Those are for you,” she mumbled.

“For me?” he wondered. At least someone appreciated his efforts. The annoyances and frustrations of the day seemed to melt away. He read the card: “Thanks for your excellent care. Mr. D and Family.” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

From time to time, headlines highlight people or organizations recognized as outliers because the outcomes of their work garner national notice. More often than not tragic, accidental outcomes rivet our attention. Occasionally, though, it is the opposite: the achievement of an outcome so unusual and inconceivably distinguished that it warrants emulation. The receipt of the 2005 Malcolm Baldrige National Quality Award by Bronson Methodist Hospital, Kalamazoo, Mich., is an example of the latter. It was no accident—this is an organization that pursues validation of its excellence assertively and enthusiastically. It is unusual because it is only the fifth healthcare organization to be counted among the ranks of Baldrige winners, and it is distinguished because the award comes from our nation’s highest elected leader.

The management team at Bronson is quick to point out that it took every employee’s involvement and enthusiasm to win this honor. Among those employees are 15 hospitalists, representing 11 full-time equivalents.

The Baldrige Award

Established in 1987 by an act of Congress, the Baldrige Award is presented annually by the President of the United States to qualifying organizations of any size in five categories: manufacturing, service, small business, education, and healthcare.

The application fee—ranging from $5,000 for large organizations to $500 for non-profit educational institutions—supports a minimum of 300 hours of review by eight or more business and quality experts, with on-site visits generating more than 1,000 hours of in-depth review. An extensive feedback report highlighting strengths and areas to improve is part of the review.

Contenders must be judged outstanding in seven areas to win. (See “Baldrige Award Criteria,” top left.) The criteria focus on two goals: delivering continuously improving value to customers and improving overall organizational performance. This helps organizations enhance their effectiveness and sustainability. Since 1999, when the Baldrige criteria for healthcare were first introduced, 116 healthcare organizations have applied.

The Beginning

According to, Katie Harrelson, RN, vice president of Patient Care Services and chief nurse executive, Bronson has always strived to be the best. In the late 1990s, they began looking at various quality models, and discovered the Baldrige Criteria.

“We began using the criteria because they provided a focus, or framework, to help us define who we are,” says Harrelson. “Physicians became partners, and patients are our customers. Bronson’s hospitalists are strong partners, and our relationship with them is great. It had to be in order to standardize care practices and continue our efforts to be a national leader in healthcare quality.”

She describes the organization’s three strategic objectives: clinical excellence, customer and service excellence, and corporate effectiveness. These “3 Cs” provide focus for Bronson and that are on the tip of all employees’ tongues.

As Bronson embarked on the journey to excellence, it already employed hospitalists. “Bronson started using hospitalists at a time when many of the community’s primary care physicians were older and retiring, or looking for an alternative admission method,” says Scott Larson, MD, senior vice president Medical Affairs and chief medical officer, “There were economic pressures, too. It’s less efficient for individual practitioners to conduct hospital rounds for a small number of patients than to use hospitalists, and hospitalists are more familiar with hospital protocol.”

By 2003 Bronson was continuing to integrate hospitalists into their program, and hospitalists were employing the precepts of performance improvement like other Bronson employees.

 

Excellence requires, among other things, good communication and unprecedented cooperation. Thus, employees from different departments and disciplines needed to identify new ways to improve existing care processes and work together as a multidisciplinary team. Hospitalists had a unique role that led to several changes.

“Hospitalists are involved in pretty much anything that happens at Bronson,” says Hussein Akl, MD, medical director for Bronson’s Hospitalist Service.

It was that involvement that led Bronson to change its approach to hip fracture care. Previously, the surgeon managed the hip fracture patient from admission to discharge. Bronson’s hospitalists proposed a new model, however: The hospitalists would manage the patient medically, leaving the surgeons to focus on what they do best: repairing the hip.

The success of the program is measured in clinical outcomes; length of stay has declined significantly since the specialists began collaborating in this way. In 2005 HealthGrades, an organization located in Golden, Colo., that rates care in 5,000 U.S. hospitals, awarded Bronson its highest rating (five stars) for hip replacement surgery and for treatment of acute myocardial infarction.

Hospitalists also took the lead in preparing for Primary Stroke Center Certification, a status Bronson achieved from the Joint Commission on Accreditation of Healthcare Organizations last year, and are leading physician engagement in Bronson’s computerized physician order entry project.

Dr. Larson emphasizes that achieving a level of excellence that meets Baldrige standards requires alignment, meaning that organizational, department or service, and individual performance goals must be congruent. Dr. Akl concurs: “Hospitalists had to align with our orthopedists to improve hip fracture care, and with neurologists on stroke.”

This level of excellence also requires constant vigilance and measurement, which is why Bronson uses scorecards to follow core indicators that reflect compliance with best practices for conditions like heart failure, and community acquired pneumonia. They also track their risk-adjusted Medicare mortality rate, which at 3.5% in 2005 was better than their 2004 rate (4.8%) and considerably better than the national average. Scorecards are distributed electronically and discussed in all meetings. Targets established at the beginning of the year are reviewed, and the hospitalist service’s performance is examined and compared with aggregate data for other admitting physicians. Management acknowledges that drilling data down to the individual level—except in rare cases—is often difficult and does not necessarily reflect an individual’s true performance.

“Patients are co-managed often, making individual provider data somewhat misleading,” explains Dr. Larson.

If recruitment and retention are an indication of employee satisfaction, Bronson’s hospitalists are satisfied. Few hospitalists have left; however, one hospitalist who left returned a year later citing Bronson’s well-structured program, the fact that all hospitalists have equal decision-making authority, and physician-based care (Bronson does not use physician extenders) as re-employment incentives.

“Of course, he said the pay was good, too,” quips Dr. Akl. At Bronson, results are rewarded and recognized generously.

The Patient’s Perspective

Bronson’s approach to hospital care translates into distinct differences—from the moment patients enter until discharge. Also recognized internationally as a Pebble Project Partner, Bronson’s facility design proves that function follows form. (See “The Pebble Project,” p. 39.) The building has a first-class hotel feel to it, with well-planned spaces and indoor gardens. Staff emphasizes privacy and service—not just care. Acknowledging that patients have needs and responsibilities outside the hospital that don’t pause while they are admitted, Bronson offers amenities such as wireless computers so patients can stay connected to their lives, beepers so family members can leave a surgical waiting area without fear of missing the surgeon’s post-operative visit, 24-hour room service, and a concierge to run errands or quarterback problems.

 

Increasingly evidence links architectural design to outcomes in many healthcare settings, and Bronson has acted on the evidence. The hospital is easy to navigate, and because a major building campaign finished this facility in 2000 every patient room is private with its own hand-washing station. Patients needn’t worry about a roommate’s noisy guest or snoring, but, more importantly, private rooms are associated with lower nosocomial infection rates and speedier recovery.

Operating and labor costs are also lower because patients are not transferred as often. At Bronson, infection rates fell 11% overall compared with the rate in their former facility that had a combination of private and semi-private rooms.

Bronson continues to monitor infection rates and also tracks employee turnover, outcome measures, length of stay, cost per unit of service, waiting times, patient satisfaction levels, nosocomial infection rates, and organizational behaviors.

Sharing Caring

Bronson’s hospitalists actively engage in information sharing. They share their protocols within the Bronson healthcare system and with other hospitals and providers. One recent project has been the successful effort to improve the discharge process—an area of emphasis for many quality-promoting oversight organizations and other facilities. Their next step is to automate their interventions.

Some also participate in a half-day Physician Leadership Academy, a gathering held quarterly to develop physician leadership skills and collaborate on identifying and implementing best practices.

Because Bronson’s overall atmosphere and organizational culture differ from older facilities or less avant-garde organizations, Harrelson, Dr. Larson, and Dr. Akl have difficulty identifying one unit where care might be considerably different than what the patient would receive elsewhere. Dr. Akl says that the hospitalists as a group discussed this question and determined that all Bronson units are held to the same high standards, but that the Adult Medical Unit (AMU) is an interesting model for serving the geriatric population.

In the AMU hospitalists lead the team to reach desirable outcomes. The unit’s propensity to admit elderly patients created unique needs that staff has met in correspondingly unique ways. Nursing’s commitment and capability is evident because all AMU nurses are NICHE (Nurses Improving Care for Health System Elders) certified. NICHE certification promotes systematic nursing change that ensures sensitive and exemplary patient-centered care for older patients. The hospitalists, too, have participated in this cultural change and created a protocol that anticipates elderly patients’ needs, and all hospitalists rotate through AMU to support this part of the continuum of care.

The Outcomes

Bronson measures everything, and uses established best practices, benchmarks, and data to ensure that they meet and exceed national standards. They monitor clinical excellence using Centers for Medicare and Medicaid Services performance rates, Blue Cross Blue Shield targets, and the CareScience (Philadelphia) database. They also follow the JCAHO standards and Leapfrog Groups’ National Quality Forum’s measures.

They monitor patient satisfaction using Gallup Polls and “listen and learn” methods that build on the idea that the customer’s opinion and experience is often more valuable than that of an outside consultant. And, they monitor corporate effectiveness using tools that measure employee learning, vacancy rates, and commitment to the environment and the community.

Bronson’s persistence and desire to be the best has paid off. Patients receive beta-blockers and pre-surgical antibiotics at rates that exceed best practice. They have significantly reduced the incidence of ventilator-acquired pneumonia in all ICUs—the pediatric ICU has had none since 2004. Patient satisfaction increased from an already high 95% in 2002 to an astounding 97% in 2004.

For the past three years, Bronson has been named by Fortune and Working Mother magazines as one of the nation’s 100 best companies to work for. They have also been named by Solucient as one of the 100 Top Hospitals in the United States for 2005. Another acknowledgment is the Environmental Leadership Award from Hospitals for a Healthy Environment for reducing waste and pollution. The list of their achievements and awards is seemingly endless, but so too is their energy to continue to improve and deliver excellent care.

 

Bronson’s approach is what it takes to earn that ultimate recognition of quality: the Malcolm Baldrige National Quality Award. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

From time to time, headlines highlight people or organizations recognized as outliers because the outcomes of their work garner national notice. More often than not tragic, accidental outcomes rivet our attention. Occasionally, though, it is the opposite: the achievement of an outcome so unusual and inconceivably distinguished that it warrants emulation. The receipt of the 2005 Malcolm Baldrige National Quality Award by Bronson Methodist Hospital, Kalamazoo, Mich., is an example of the latter. It was no accident—this is an organization that pursues validation of its excellence assertively and enthusiastically. It is unusual because it is only the fifth healthcare organization to be counted among the ranks of Baldrige winners, and it is distinguished because the award comes from our nation’s highest elected leader.

The management team at Bronson is quick to point out that it took every employee’s involvement and enthusiasm to win this honor. Among those employees are 15 hospitalists, representing 11 full-time equivalents.

The Baldrige Award

Established in 1987 by an act of Congress, the Baldrige Award is presented annually by the President of the United States to qualifying organizations of any size in five categories: manufacturing, service, small business, education, and healthcare.

The application fee—ranging from $5,000 for large organizations to $500 for non-profit educational institutions—supports a minimum of 300 hours of review by eight or more business and quality experts, with on-site visits generating more than 1,000 hours of in-depth review. An extensive feedback report highlighting strengths and areas to improve is part of the review.

Contenders must be judged outstanding in seven areas to win. (See “Baldrige Award Criteria,” top left.) The criteria focus on two goals: delivering continuously improving value to customers and improving overall organizational performance. This helps organizations enhance their effectiveness and sustainability. Since 1999, when the Baldrige criteria for healthcare were first introduced, 116 healthcare organizations have applied.

The Beginning

According to, Katie Harrelson, RN, vice president of Patient Care Services and chief nurse executive, Bronson has always strived to be the best. In the late 1990s, they began looking at various quality models, and discovered the Baldrige Criteria.

“We began using the criteria because they provided a focus, or framework, to help us define who we are,” says Harrelson. “Physicians became partners, and patients are our customers. Bronson’s hospitalists are strong partners, and our relationship with them is great. It had to be in order to standardize care practices and continue our efforts to be a national leader in healthcare quality.”

She describes the organization’s three strategic objectives: clinical excellence, customer and service excellence, and corporate effectiveness. These “3 Cs” provide focus for Bronson and that are on the tip of all employees’ tongues.

As Bronson embarked on the journey to excellence, it already employed hospitalists. “Bronson started using hospitalists at a time when many of the community’s primary care physicians were older and retiring, or looking for an alternative admission method,” says Scott Larson, MD, senior vice president Medical Affairs and chief medical officer, “There were economic pressures, too. It’s less efficient for individual practitioners to conduct hospital rounds for a small number of patients than to use hospitalists, and hospitalists are more familiar with hospital protocol.”

By 2003 Bronson was continuing to integrate hospitalists into their program, and hospitalists were employing the precepts of performance improvement like other Bronson employees.

 

Excellence requires, among other things, good communication and unprecedented cooperation. Thus, employees from different departments and disciplines needed to identify new ways to improve existing care processes and work together as a multidisciplinary team. Hospitalists had a unique role that led to several changes.

“Hospitalists are involved in pretty much anything that happens at Bronson,” says Hussein Akl, MD, medical director for Bronson’s Hospitalist Service.

It was that involvement that led Bronson to change its approach to hip fracture care. Previously, the surgeon managed the hip fracture patient from admission to discharge. Bronson’s hospitalists proposed a new model, however: The hospitalists would manage the patient medically, leaving the surgeons to focus on what they do best: repairing the hip.

The success of the program is measured in clinical outcomes; length of stay has declined significantly since the specialists began collaborating in this way. In 2005 HealthGrades, an organization located in Golden, Colo., that rates care in 5,000 U.S. hospitals, awarded Bronson its highest rating (five stars) for hip replacement surgery and for treatment of acute myocardial infarction.

Hospitalists also took the lead in preparing for Primary Stroke Center Certification, a status Bronson achieved from the Joint Commission on Accreditation of Healthcare Organizations last year, and are leading physician engagement in Bronson’s computerized physician order entry project.

Dr. Larson emphasizes that achieving a level of excellence that meets Baldrige standards requires alignment, meaning that organizational, department or service, and individual performance goals must be congruent. Dr. Akl concurs: “Hospitalists had to align with our orthopedists to improve hip fracture care, and with neurologists on stroke.”

This level of excellence also requires constant vigilance and measurement, which is why Bronson uses scorecards to follow core indicators that reflect compliance with best practices for conditions like heart failure, and community acquired pneumonia. They also track their risk-adjusted Medicare mortality rate, which at 3.5% in 2005 was better than their 2004 rate (4.8%) and considerably better than the national average. Scorecards are distributed electronically and discussed in all meetings. Targets established at the beginning of the year are reviewed, and the hospitalist service’s performance is examined and compared with aggregate data for other admitting physicians. Management acknowledges that drilling data down to the individual level—except in rare cases—is often difficult and does not necessarily reflect an individual’s true performance.

“Patients are co-managed often, making individual provider data somewhat misleading,” explains Dr. Larson.

If recruitment and retention are an indication of employee satisfaction, Bronson’s hospitalists are satisfied. Few hospitalists have left; however, one hospitalist who left returned a year later citing Bronson’s well-structured program, the fact that all hospitalists have equal decision-making authority, and physician-based care (Bronson does not use physician extenders) as re-employment incentives.

“Of course, he said the pay was good, too,” quips Dr. Akl. At Bronson, results are rewarded and recognized generously.

The Patient’s Perspective

Bronson’s approach to hospital care translates into distinct differences—from the moment patients enter until discharge. Also recognized internationally as a Pebble Project Partner, Bronson’s facility design proves that function follows form. (See “The Pebble Project,” p. 39.) The building has a first-class hotel feel to it, with well-planned spaces and indoor gardens. Staff emphasizes privacy and service—not just care. Acknowledging that patients have needs and responsibilities outside the hospital that don’t pause while they are admitted, Bronson offers amenities such as wireless computers so patients can stay connected to their lives, beepers so family members can leave a surgical waiting area without fear of missing the surgeon’s post-operative visit, 24-hour room service, and a concierge to run errands or quarterback problems.

 

Increasingly evidence links architectural design to outcomes in many healthcare settings, and Bronson has acted on the evidence. The hospital is easy to navigate, and because a major building campaign finished this facility in 2000 every patient room is private with its own hand-washing station. Patients needn’t worry about a roommate’s noisy guest or snoring, but, more importantly, private rooms are associated with lower nosocomial infection rates and speedier recovery.

Operating and labor costs are also lower because patients are not transferred as often. At Bronson, infection rates fell 11% overall compared with the rate in their former facility that had a combination of private and semi-private rooms.

Bronson continues to monitor infection rates and also tracks employee turnover, outcome measures, length of stay, cost per unit of service, waiting times, patient satisfaction levels, nosocomial infection rates, and organizational behaviors.

Sharing Caring

Bronson’s hospitalists actively engage in information sharing. They share their protocols within the Bronson healthcare system and with other hospitals and providers. One recent project has been the successful effort to improve the discharge process—an area of emphasis for many quality-promoting oversight organizations and other facilities. Their next step is to automate their interventions.

Some also participate in a half-day Physician Leadership Academy, a gathering held quarterly to develop physician leadership skills and collaborate on identifying and implementing best practices.

Because Bronson’s overall atmosphere and organizational culture differ from older facilities or less avant-garde organizations, Harrelson, Dr. Larson, and Dr. Akl have difficulty identifying one unit where care might be considerably different than what the patient would receive elsewhere. Dr. Akl says that the hospitalists as a group discussed this question and determined that all Bronson units are held to the same high standards, but that the Adult Medical Unit (AMU) is an interesting model for serving the geriatric population.

In the AMU hospitalists lead the team to reach desirable outcomes. The unit’s propensity to admit elderly patients created unique needs that staff has met in correspondingly unique ways. Nursing’s commitment and capability is evident because all AMU nurses are NICHE (Nurses Improving Care for Health System Elders) certified. NICHE certification promotes systematic nursing change that ensures sensitive and exemplary patient-centered care for older patients. The hospitalists, too, have participated in this cultural change and created a protocol that anticipates elderly patients’ needs, and all hospitalists rotate through AMU to support this part of the continuum of care.

The Outcomes

Bronson measures everything, and uses established best practices, benchmarks, and data to ensure that they meet and exceed national standards. They monitor clinical excellence using Centers for Medicare and Medicaid Services performance rates, Blue Cross Blue Shield targets, and the CareScience (Philadelphia) database. They also follow the JCAHO standards and Leapfrog Groups’ National Quality Forum’s measures.

They monitor patient satisfaction using Gallup Polls and “listen and learn” methods that build on the idea that the customer’s opinion and experience is often more valuable than that of an outside consultant. And, they monitor corporate effectiveness using tools that measure employee learning, vacancy rates, and commitment to the environment and the community.

Bronson’s persistence and desire to be the best has paid off. Patients receive beta-blockers and pre-surgical antibiotics at rates that exceed best practice. They have significantly reduced the incidence of ventilator-acquired pneumonia in all ICUs—the pediatric ICU has had none since 2004. Patient satisfaction increased from an already high 95% in 2002 to an astounding 97% in 2004.

For the past three years, Bronson has been named by Fortune and Working Mother magazines as one of the nation’s 100 best companies to work for. They have also been named by Solucient as one of the 100 Top Hospitals in the United States for 2005. Another acknowledgment is the Environmental Leadership Award from Hospitals for a Healthy Environment for reducing waste and pollution. The list of their achievements and awards is seemingly endless, but so too is their energy to continue to improve and deliver excellent care.

 

Bronson’s approach is what it takes to earn that ultimate recognition of quality: the Malcolm Baldrige National Quality Award. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

From time to time, headlines highlight people or organizations recognized as outliers because the outcomes of their work garner national notice. More often than not tragic, accidental outcomes rivet our attention. Occasionally, though, it is the opposite: the achievement of an outcome so unusual and inconceivably distinguished that it warrants emulation. The receipt of the 2005 Malcolm Baldrige National Quality Award by Bronson Methodist Hospital, Kalamazoo, Mich., is an example of the latter. It was no accident—this is an organization that pursues validation of its excellence assertively and enthusiastically. It is unusual because it is only the fifth healthcare organization to be counted among the ranks of Baldrige winners, and it is distinguished because the award comes from our nation’s highest elected leader.

The management team at Bronson is quick to point out that it took every employee’s involvement and enthusiasm to win this honor. Among those employees are 15 hospitalists, representing 11 full-time equivalents.

The Baldrige Award

Established in 1987 by an act of Congress, the Baldrige Award is presented annually by the President of the United States to qualifying organizations of any size in five categories: manufacturing, service, small business, education, and healthcare.

The application fee—ranging from $5,000 for large organizations to $500 for non-profit educational institutions—supports a minimum of 300 hours of review by eight or more business and quality experts, with on-site visits generating more than 1,000 hours of in-depth review. An extensive feedback report highlighting strengths and areas to improve is part of the review.

Contenders must be judged outstanding in seven areas to win. (See “Baldrige Award Criteria,” top left.) The criteria focus on two goals: delivering continuously improving value to customers and improving overall organizational performance. This helps organizations enhance their effectiveness and sustainability. Since 1999, when the Baldrige criteria for healthcare were first introduced, 116 healthcare organizations have applied.

The Beginning

According to, Katie Harrelson, RN, vice president of Patient Care Services and chief nurse executive, Bronson has always strived to be the best. In the late 1990s, they began looking at various quality models, and discovered the Baldrige Criteria.

“We began using the criteria because they provided a focus, or framework, to help us define who we are,” says Harrelson. “Physicians became partners, and patients are our customers. Bronson’s hospitalists are strong partners, and our relationship with them is great. It had to be in order to standardize care practices and continue our efforts to be a national leader in healthcare quality.”

She describes the organization’s three strategic objectives: clinical excellence, customer and service excellence, and corporate effectiveness. These “3 Cs” provide focus for Bronson and that are on the tip of all employees’ tongues.

As Bronson embarked on the journey to excellence, it already employed hospitalists. “Bronson started using hospitalists at a time when many of the community’s primary care physicians were older and retiring, or looking for an alternative admission method,” says Scott Larson, MD, senior vice president Medical Affairs and chief medical officer, “There were economic pressures, too. It’s less efficient for individual practitioners to conduct hospital rounds for a small number of patients than to use hospitalists, and hospitalists are more familiar with hospital protocol.”

By 2003 Bronson was continuing to integrate hospitalists into their program, and hospitalists were employing the precepts of performance improvement like other Bronson employees.

 

Excellence requires, among other things, good communication and unprecedented cooperation. Thus, employees from different departments and disciplines needed to identify new ways to improve existing care processes and work together as a multidisciplinary team. Hospitalists had a unique role that led to several changes.

“Hospitalists are involved in pretty much anything that happens at Bronson,” says Hussein Akl, MD, medical director for Bronson’s Hospitalist Service.

It was that involvement that led Bronson to change its approach to hip fracture care. Previously, the surgeon managed the hip fracture patient from admission to discharge. Bronson’s hospitalists proposed a new model, however: The hospitalists would manage the patient medically, leaving the surgeons to focus on what they do best: repairing the hip.

The success of the program is measured in clinical outcomes; length of stay has declined significantly since the specialists began collaborating in this way. In 2005 HealthGrades, an organization located in Golden, Colo., that rates care in 5,000 U.S. hospitals, awarded Bronson its highest rating (five stars) for hip replacement surgery and for treatment of acute myocardial infarction.

Hospitalists also took the lead in preparing for Primary Stroke Center Certification, a status Bronson achieved from the Joint Commission on Accreditation of Healthcare Organizations last year, and are leading physician engagement in Bronson’s computerized physician order entry project.

Dr. Larson emphasizes that achieving a level of excellence that meets Baldrige standards requires alignment, meaning that organizational, department or service, and individual performance goals must be congruent. Dr. Akl concurs: “Hospitalists had to align with our orthopedists to improve hip fracture care, and with neurologists on stroke.”

This level of excellence also requires constant vigilance and measurement, which is why Bronson uses scorecards to follow core indicators that reflect compliance with best practices for conditions like heart failure, and community acquired pneumonia. They also track their risk-adjusted Medicare mortality rate, which at 3.5% in 2005 was better than their 2004 rate (4.8%) and considerably better than the national average. Scorecards are distributed electronically and discussed in all meetings. Targets established at the beginning of the year are reviewed, and the hospitalist service’s performance is examined and compared with aggregate data for other admitting physicians. Management acknowledges that drilling data down to the individual level—except in rare cases—is often difficult and does not necessarily reflect an individual’s true performance.

“Patients are co-managed often, making individual provider data somewhat misleading,” explains Dr. Larson.

If recruitment and retention are an indication of employee satisfaction, Bronson’s hospitalists are satisfied. Few hospitalists have left; however, one hospitalist who left returned a year later citing Bronson’s well-structured program, the fact that all hospitalists have equal decision-making authority, and physician-based care (Bronson does not use physician extenders) as re-employment incentives.

“Of course, he said the pay was good, too,” quips Dr. Akl. At Bronson, results are rewarded and recognized generously.

The Patient’s Perspective

Bronson’s approach to hospital care translates into distinct differences—from the moment patients enter until discharge. Also recognized internationally as a Pebble Project Partner, Bronson’s facility design proves that function follows form. (See “The Pebble Project,” p. 39.) The building has a first-class hotel feel to it, with well-planned spaces and indoor gardens. Staff emphasizes privacy and service—not just care. Acknowledging that patients have needs and responsibilities outside the hospital that don’t pause while they are admitted, Bronson offers amenities such as wireless computers so patients can stay connected to their lives, beepers so family members can leave a surgical waiting area without fear of missing the surgeon’s post-operative visit, 24-hour room service, and a concierge to run errands or quarterback problems.

 

Increasingly evidence links architectural design to outcomes in many healthcare settings, and Bronson has acted on the evidence. The hospital is easy to navigate, and because a major building campaign finished this facility in 2000 every patient room is private with its own hand-washing station. Patients needn’t worry about a roommate’s noisy guest or snoring, but, more importantly, private rooms are associated with lower nosocomial infection rates and speedier recovery.

Operating and labor costs are also lower because patients are not transferred as often. At Bronson, infection rates fell 11% overall compared with the rate in their former facility that had a combination of private and semi-private rooms.

Bronson continues to monitor infection rates and also tracks employee turnover, outcome measures, length of stay, cost per unit of service, waiting times, patient satisfaction levels, nosocomial infection rates, and organizational behaviors.

Sharing Caring

Bronson’s hospitalists actively engage in information sharing. They share their protocols within the Bronson healthcare system and with other hospitals and providers. One recent project has been the successful effort to improve the discharge process—an area of emphasis for many quality-promoting oversight organizations and other facilities. Their next step is to automate their interventions.

Some also participate in a half-day Physician Leadership Academy, a gathering held quarterly to develop physician leadership skills and collaborate on identifying and implementing best practices.

Because Bronson’s overall atmosphere and organizational culture differ from older facilities or less avant-garde organizations, Harrelson, Dr. Larson, and Dr. Akl have difficulty identifying one unit where care might be considerably different than what the patient would receive elsewhere. Dr. Akl says that the hospitalists as a group discussed this question and determined that all Bronson units are held to the same high standards, but that the Adult Medical Unit (AMU) is an interesting model for serving the geriatric population.

In the AMU hospitalists lead the team to reach desirable outcomes. The unit’s propensity to admit elderly patients created unique needs that staff has met in correspondingly unique ways. Nursing’s commitment and capability is evident because all AMU nurses are NICHE (Nurses Improving Care for Health System Elders) certified. NICHE certification promotes systematic nursing change that ensures sensitive and exemplary patient-centered care for older patients. The hospitalists, too, have participated in this cultural change and created a protocol that anticipates elderly patients’ needs, and all hospitalists rotate through AMU to support this part of the continuum of care.

The Outcomes

Bronson measures everything, and uses established best practices, benchmarks, and data to ensure that they meet and exceed national standards. They monitor clinical excellence using Centers for Medicare and Medicaid Services performance rates, Blue Cross Blue Shield targets, and the CareScience (Philadelphia) database. They also follow the JCAHO standards and Leapfrog Groups’ National Quality Forum’s measures.

They monitor patient satisfaction using Gallup Polls and “listen and learn” methods that build on the idea that the customer’s opinion and experience is often more valuable than that of an outside consultant. And, they monitor corporate effectiveness using tools that measure employee learning, vacancy rates, and commitment to the environment and the community.

Bronson’s persistence and desire to be the best has paid off. Patients receive beta-blockers and pre-surgical antibiotics at rates that exceed best practice. They have significantly reduced the incidence of ventilator-acquired pneumonia in all ICUs—the pediatric ICU has had none since 2004. Patient satisfaction increased from an already high 95% in 2002 to an astounding 97% in 2004.

For the past three years, Bronson has been named by Fortune and Working Mother magazines as one of the nation’s 100 best companies to work for. They have also been named by Solucient as one of the 100 Top Hospitals in the United States for 2005. Another acknowledgment is the Environmental Leadership Award from Hospitals for a Healthy Environment for reducing waste and pollution. The list of their achievements and awards is seemingly endless, but so too is their energy to continue to improve and deliver excellent care.

 

Bronson’s approach is what it takes to earn that ultimate recognition of quality: the Malcolm Baldrige National Quality Award. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

This article is the first in a two-part series on the CMS Physician Voluntary Reporting Program. Part two will appear in the June issue.

How aware are you of impending policies and programs that will shape how you work and get compensated? Changes are on the horizon that will affect physicians in the immediate future, including their relationship with the Centers for Medicare and Medicaid (CMS).

Your future began to change on Jan. 3, 2006, when CMS activated its Physician Voluntary Reporting Program (PVRP). The program truly is voluntary—physicians are free to decide whether they want to participate. There is no financial reward for participation, but participants receive feedback from CMS that can help them improve clinical care and data accuracy. They also get in on the ground floor of a program that is almost certain to evolve into a mandatory reporting system, and possibly a CMS pay-for-performance program.

The American College of Physicians has stated that, “While physicians are under no obligation to participate in the voluntary program, practices that choose to do so may get a sneak preview of CMS’ future pay-for-performance plans.”

Although SHM has no official position on PVRP, Eric Siegal, MD, chair of SHM’s Public Policy Committee, says that the committee has spent a “fair amount of time” examining the program. The group is interested because, as Dr. Siegal says, “Reporting of quality outcomes is the wave of the future.”

An Overview of the Program

What are physicians volunteering to report to CMS? Participating doctors help capture data on the quality of care they provide to Medicare beneficiaries. They report on any (or any applicable) of 16 evidence-based quality measures, each one comprising two to four Healthcare Common Procedure Coding System (HCPCS) codes called G-codes. (See “16 Clinical Measures,” below, for a list of the quality measures.)

Voluntary reporting is done through the existing administrative system for claims. CMS then analyzes the data and measures the quality of services provided to Medicare patients, providing reporting physicians with confidential information on their performance.

Where Do Hospitalists Fit in?

The bright side for hospitalists is that they should have little problem with the reporting requirements of PVRP. “Hospitalists should be used to being measured, because hospitals have been reporting our adherence to quality measures through the [CMS] Hospital Compare Program,” says Dr. Siegal.

However, it’s obvious that PVRP is not designed for all physicians. “We’ve looked at the metrics, and the majority aren’t applicable to hospitalists,” points out Dr. Siegal. “But some are very relevant to us.” CMS is aware of hospitalists’ position regarding the program. Trent Heywood, deputy chief medical officer, CMS, says, “In this construct, hospitalists are in a unique situation. [They] are kind of in between—the question is whether they’re managing the patient. We’re asking things like how well was diabetes controlled and was the blood pressure controlled.”

Regardless of areas of mismatch, hospitalists can certainly participate in voluntary reporting. “I think that we should embrace the PVRP, even though only a few of the measures in the starter set are directly relevant to hospitalists,” says Dr. Siegal. “This program is the first step in a process that will dramatically change the way we are paid for our work. It will be easier to engage it now, when there are only a few metrics, than later when it’s much more pervasive.”

 

Meanwhile, CMS may need to juggle the reporting role of hospitalists as the program evolves. “What we don’t want to end up with is perverse incentives, where hospitals and physicians have different and potentially misaligned metrics to report,” stresses Dr. Siegal. “We have to make sure that our incentives are aligned. If possible, we should have a system that allows hospitals and hospitalists to share data and reduce the administrative burden required to report our compliance.”

Heywood agrees. “There will continue to be more dialogue about how to deal with this issue,” he says of the hospitalist role in PVRP. “How do we engage the hospitalist? Are they assumed to be on the hospital side or the physician side? We want all physicians on the same side, but that will take some time.”

Time will tell how voluntary reporting will work for hospitalists. Next month, part two of this article will examine the pros and cons of participating now.

For more information on the PVRP, including instructions on how to sign up, visit www.cms.hhs.gov/PVRP/01_Overview.asp. TH

Jane Jerrard regularly writes the “Public Policy” department.

This article is the first in a two-part series on the CMS Physician Voluntary Reporting Program. Part two will appear in the June issue.

How aware are you of impending policies and programs that will shape how you work and get compensated? Changes are on the horizon that will affect physicians in the immediate future, including their relationship with the Centers for Medicare and Medicaid (CMS).

Your future began to change on Jan. 3, 2006, when CMS activated its Physician Voluntary Reporting Program (PVRP). The program truly is voluntary—physicians are free to decide whether they want to participate. There is no financial reward for participation, but participants receive feedback from CMS that can help them improve clinical care and data accuracy. They also get in on the ground floor of a program that is almost certain to evolve into a mandatory reporting system, and possibly a CMS pay-for-performance program.

The American College of Physicians has stated that, “While physicians are under no obligation to participate in the voluntary program, practices that choose to do so may get a sneak preview of CMS’ future pay-for-performance plans.”

Although SHM has no official position on PVRP, Eric Siegal, MD, chair of SHM’s Public Policy Committee, says that the committee has spent a “fair amount of time” examining the program. The group is interested because, as Dr. Siegal says, “Reporting of quality outcomes is the wave of the future.”

An Overview of the Program

What are physicians volunteering to report to CMS? Participating doctors help capture data on the quality of care they provide to Medicare beneficiaries. They report on any (or any applicable) of 16 evidence-based quality measures, each one comprising two to four Healthcare Common Procedure Coding System (HCPCS) codes called G-codes. (See “16 Clinical Measures,” below, for a list of the quality measures.)

Voluntary reporting is done through the existing administrative system for claims. CMS then analyzes the data and measures the quality of services provided to Medicare patients, providing reporting physicians with confidential information on their performance.

Where Do Hospitalists Fit in?

The bright side for hospitalists is that they should have little problem with the reporting requirements of PVRP. “Hospitalists should be used to being measured, because hospitals have been reporting our adherence to quality measures through the [CMS] Hospital Compare Program,” says Dr. Siegal.

However, it’s obvious that PVRP is not designed for all physicians. “We’ve looked at the metrics, and the majority aren’t applicable to hospitalists,” points out Dr. Siegal. “But some are very relevant to us.” CMS is aware of hospitalists’ position regarding the program. Trent Heywood, deputy chief medical officer, CMS, says, “In this construct, hospitalists are in a unique situation. [They] are kind of in between—the question is whether they’re managing the patient. We’re asking things like how well was diabetes controlled and was the blood pressure controlled.”

Regardless of areas of mismatch, hospitalists can certainly participate in voluntary reporting. “I think that we should embrace the PVRP, even though only a few of the measures in the starter set are directly relevant to hospitalists,” says Dr. Siegal. “This program is the first step in a process that will dramatically change the way we are paid for our work. It will be easier to engage it now, when there are only a few metrics, than later when it’s much more pervasive.”

 

Meanwhile, CMS may need to juggle the reporting role of hospitalists as the program evolves. “What we don’t want to end up with is perverse incentives, where hospitals and physicians have different and potentially misaligned metrics to report,” stresses Dr. Siegal. “We have to make sure that our incentives are aligned. If possible, we should have a system that allows hospitals and hospitalists to share data and reduce the administrative burden required to report our compliance.”

Heywood agrees. “There will continue to be more dialogue about how to deal with this issue,” he says of the hospitalist role in PVRP. “How do we engage the hospitalist? Are they assumed to be on the hospital side or the physician side? We want all physicians on the same side, but that will take some time.”

Time will tell how voluntary reporting will work for hospitalists. Next month, part two of this article will examine the pros and cons of participating now.

For more information on the PVRP, including instructions on how to sign up, visit www.cms.hhs.gov/PVRP/01_Overview.asp. TH

Jane Jerrard regularly writes the “Public Policy” department.

This article is the first in a two-part series on the CMS Physician Voluntary Reporting Program. Part two will appear in the June issue.

How aware are you of impending policies and programs that will shape how you work and get compensated? Changes are on the horizon that will affect physicians in the immediate future, including their relationship with the Centers for Medicare and Medicaid (CMS).

Your future began to change on Jan. 3, 2006, when CMS activated its Physician Voluntary Reporting Program (PVRP). The program truly is voluntary—physicians are free to decide whether they want to participate. There is no financial reward for participation, but participants receive feedback from CMS that can help them improve clinical care and data accuracy. They also get in on the ground floor of a program that is almost certain to evolve into a mandatory reporting system, and possibly a CMS pay-for-performance program.

The American College of Physicians has stated that, “While physicians are under no obligation to participate in the voluntary program, practices that choose to do so may get a sneak preview of CMS’ future pay-for-performance plans.”

Although SHM has no official position on PVRP, Eric Siegal, MD, chair of SHM’s Public Policy Committee, says that the committee has spent a “fair amount of time” examining the program. The group is interested because, as Dr. Siegal says, “Reporting of quality outcomes is the wave of the future.”

An Overview of the Program

What are physicians volunteering to report to CMS? Participating doctors help capture data on the quality of care they provide to Medicare beneficiaries. They report on any (or any applicable) of 16 evidence-based quality measures, each one comprising two to four Healthcare Common Procedure Coding System (HCPCS) codes called G-codes. (See “16 Clinical Measures,” below, for a list of the quality measures.)

Voluntary reporting is done through the existing administrative system for claims. CMS then analyzes the data and measures the quality of services provided to Medicare patients, providing reporting physicians with confidential information on their performance.

Where Do Hospitalists Fit in?

The bright side for hospitalists is that they should have little problem with the reporting requirements of PVRP. “Hospitalists should be used to being measured, because hospitals have been reporting our adherence to quality measures through the [CMS] Hospital Compare Program,” says Dr. Siegal.

However, it’s obvious that PVRP is not designed for all physicians. “We’ve looked at the metrics, and the majority aren’t applicable to hospitalists,” points out Dr. Siegal. “But some are very relevant to us.” CMS is aware of hospitalists’ position regarding the program. Trent Heywood, deputy chief medical officer, CMS, says, “In this construct, hospitalists are in a unique situation. [They] are kind of in between—the question is whether they’re managing the patient. We’re asking things like how well was diabetes controlled and was the blood pressure controlled.”

Regardless of areas of mismatch, hospitalists can certainly participate in voluntary reporting. “I think that we should embrace the PVRP, even though only a few of the measures in the starter set are directly relevant to hospitalists,” says Dr. Siegal. “This program is the first step in a process that will dramatically change the way we are paid for our work. It will be easier to engage it now, when there are only a few metrics, than later when it’s much more pervasive.”

 

Meanwhile, CMS may need to juggle the reporting role of hospitalists as the program evolves. “What we don’t want to end up with is perverse incentives, where hospitals and physicians have different and potentially misaligned metrics to report,” stresses Dr. Siegal. “We have to make sure that our incentives are aligned. If possible, we should have a system that allows hospitals and hospitalists to share data and reduce the administrative burden required to report our compliance.”

Heywood agrees. “There will continue to be more dialogue about how to deal with this issue,” he says of the hospitalist role in PVRP. “How do we engage the hospitalist? Are they assumed to be on the hospital side or the physician side? We want all physicians on the same side, but that will take some time.”

Time will tell how voluntary reporting will work for hospitalists. Next month, part two of this article will examine the pros and cons of participating now.

For more information on the PVRP, including instructions on how to sign up, visit www.cms.hhs.gov/PVRP/01_Overview.asp. TH

Jane Jerrard regularly writes the “Public Policy” department.

This month SHM presents its 2006 national awards of excellence to five hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of patient care and hospital quality improvement across America. The award winners will be recognized at SHM’s 2006 annual meeting in Washington, D.C., on May 5 from 11:35 a.m. to 1:35 p.m. They include:

• Howard Epstein, MD—Award for Clinical Excellence
• Christopher P. Landrigan, MD, MPH—Excellence in Research Award
• Sylvia McKean, MD, FACP—Excellence in Teaching Award
• Erin Ragan Stucky, MD—Award for Outstanding Service in Hospital Medicine
• Thomas J. Yacovella, MD—Excellence in Teaching Award

“SHM is very pleased each year to recognize the hospitalist leaders among us who consistently go above and beyond to champion hospital medicine, to expand the role of hospitalists in areas of patient care and hospital leadership, and to enhance the quality of care, communication, and service we provide,” says Larry Wellikson, CEO of SHM. “These individuals are a true inspiration to us and we congratulate them all for their many accomplishments.”

Dr. Epstein is a recognized leader in the development of clinical excellence and standardization of care in hospital medicine in Minnesota and nationally, and has championed the role of the hospitalist as part of an interdisciplinary team. He currently works with HealthPartners Medical Group at Regions Hospital in St. Paul, Minn., where he is a hospitalist and medical director of the Care Management and Palliative Care Departments. He also is an assistant clinical professor of medicine at the University of Minnesota.

As one of HealthPartners’ first hospitalists, he introduced “Implementation of MCAP Guidelines,” which produced significant improvements in resource utilization. As Regions Hospital’s first medical director for Care Management, he has been instrumental in expanding the role of the Medical Management Steering Committee to routinely incorporate data collection, analysis, and implementation of quality improvement strategies across the care continuum, thus elevating the value of Care Management and enhancing patient care.

Best known for his clinical focus on palliative care, Dr. Esptein established Regions’ Palliative Care Team, the first inpatient program in St. Paul. There he developed a model for palliative care that has improved patient quality of life, eased family suffering, and lessened the use of unnecessary resources at the end of life.

A member of the Institute for Clinical Systems Improvement, a collaborative organization of 57 healthcare organizations and nearly 80% of the physicians in Minnesota, Dr. Epstein has provided leadership in the development of clinical practice guidelines, order sets, healthcare protocols and technology assessments, and the production of standardized, evidence-based hospital order sets used across the state.

A tireless proponent of Hospital Medicine, Dr. Epstein founded the Minnesota Hospitalist Association (now a chapter of SHM) and is a frequent speaker on hospitalists and inpatient palliative care. He currently serves on SHM’s Ethics Committee and Palliative Care Task Force, and will lecture on “The Basic Why and and How to Develop a Hospital-Based Palliative Care Program” on May 5 from 1:35 to 3:05 p.m. at the SHM 2006 Annual Meeting.

Dr. Epstein earned his undergraduate degree and medical degree from Washington University in St. Louis. He completed his residency in internal medicine at the University of Minnesota (Minneapolis) in 1994 and joined the teaching faculty at St. Paul-Ramsey Medical Center (now Regions Hospital) that same year.

Dr. Landrigan has rapidly established himself as one of the nation’s leading investigators in hospital medicine and patient safety, and is a pioneer in academic pediatric hospital medicine. In only a few short years, he has participated in landmark investigative projects, including the establishment of the Pediatric Research in the Inpatient Setting (PRIS) network and the creation of a second textbook for pediatric hospital medicine. The PRIS network is modeled after the American Academy of Pediatrics’ (AAP) successful Pediatric Research in the Outpatient Setting (PROS) network.

 

Dr. Landrigan was the first physician in the United States to complete a fellowship in pediatric hospital medicine, and he focused his research on the future of the field and on evaluating efficiency, quality of care, patient experience, and education in pediatric hospitalist systems. His first published papers helped to define the direction of pediatric hospital medicine.

Dr. Landrigan currently is a pediatric hospitalist at Children’s Hospital Boston, where he is also research director of the Children’s Hospital Inpatient Pediatric Service (CHIPS), and is a pediatric hospitalist fellowship director. At CHIPS, he co-authored one of the first papers to examine medication errors and adverse drug events in the pediatric population, which was published in JAMA (Kaushal R, Bates DW, Landrigan C, et al. Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA. 2001 Apr(285):2114-2120).

Dr. Landrigan also is director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, Boston, and is an assistant professor at Harvard Medical School (Boston). His interest in the role of sleep deprivation in patient safety spurred him to work with a team at Harvard on a project assessing the effects of physician/staff sleep deprivation on patient safety.

As project director of the Harvard Work Hours, Health, and Safety Study, he was lead investigator on an October 2005 New England Journal of Medicine study that demonstrated that interns working industry-sanctioned work schedules with recurrent 30-hour shifts made 36% more serious medical errors, and more than five times as many serious diagnostic errors than interns whose scheduled work was limited to 16 consecutive hours (Pennel NA, Liu JF, Mazzini MJ, et al. Interns’ work hours. N Engl J Med. 2005;352:726-728). This study led to other related studies evaluating the effect of industry-sanctioned work schedules, and sleep deprivation and patient safety, resulting in improvements to the standards.

Dr. Landrigan joined SHM in 1998 as a charter member and has served on the Pediatric Committee since 2002. From 2003-2004 he was also a member of the Research Abstract Committee.

Dr. Landrigan earned his undergraduate degree in 1991 and went on to earn his MD from Mount Sinai Medical School, New York City, and his MPH from Harvard School of Public Health, Boston. He completed his residency in pediatrics at Children’s Hospital Boston and his fellowship in general pediatrics there. He joined the Harvard faculty as instructor in 2000, and was promoted to assistant professor in 2004.

Dr. Stucky is recognized as an innovator in pediatrics and has been one of the nation’s most influential pediatric hospitalists. She has participated in landmark projects advancing pediatric medicine, including the establishment of the PRIS network and the development of the nation’s first pediatric hospital medicine core curriculum program to help define the skills and knowledge base needed for the practice of pediatric hospital medicine.

Dr. Stucky is a pediatric hospitalist at San Diego Children’s Hospital-University of California, where she is also director of the Hospital’s Graduate Medical Education. Dr. Stucky also directs the inpatient teaching service for four area-wide pediatric residency programs, oversees a core lecture series for trainees, and serves on multiple UCSD pediatric residency, intern, and education committees. In conjunction with UCSD, Dr. Stucky also participates in a national collaborative research project with the U.S. Department of Veterans Affairs. As site director for the project, she is finalizing data on medication errors and stress management in hospitalists and residents over a one-year period.

In the public policy arena, Dr. Stucky has distinguished herself as an author and a co-author of a number of policy statements. She was the lead author of the AAP’s policy statement “Prevention of Medication Errors in the Pediatric Inpatient Setting,” which outlines the importance of creating an environment of medication safety. On behalf of the AAP, Dr. Stucky challenged the Joint Council on the Accreditation of Healthcare Organizations (JCAHO) on one of its 2004 national patient safety goals requiring that hospitals caring for neonatal and pediatric patients rapidly eliminate the long-standing “rule of 6” method for administering drug dosages in favor of standardized drip concentrations.

 

Dr. Stucky led a diverse group that convinced JCAHO to develop an alternative proposal. As a result of her persistence, hospitals now have the appropriate time to comply with the new rules.

Because of Dr. Stucky’s clinical credibility and personal collaborative style, she has been successful in co-authoring and completing many controversial policies requiring negotiation and resolution of different interests. She is widely sought after as a reviewer of policies, offering opinions to the Centers for Disease Control and Prevention, Institute of Medicine, and others.

A long-standing member of SHM’s Pediatric Committee, Dr. Stucky has presented an “Update in Pediatric Hospital Medicine” at SHM’s annual meeting for the past three years, and was a plenary speaker at the 2005 tri-sponsored (AAP, the Ambulatory Pediatric Association, and SHM) pediatric hospital medicine conference in Denver—the largest-ever gathering of pediatric hospitalists.

Throughout her career, Dr. Stucky has been the recipient of numerous regional and national awards, including: Best Doctors in America Award (2005); San Diego Magazine’s Best Doctors (2003, 2002); American Academy of Family Physicians “Active Teacher in Family Medicine” Award from the Camp Pendleton Family Practice Program (2002); and the Physician Leadership Award Children’s Hospital (2000).

Dr. Stucky earned her bachelor of science degree in biology from Stanford University and received her MD from the University of California at San Francisco in 1988. She performed her residency at UCSD before becoming chief resident there from 1991-1992.

Dr. McKean is an associate physician in the Division of General Internal Medicine at Brigham and Women’s Hospital, Boston, and is medical director of the Brigham and Women’s and Faulkner Hospitals Hospitalist Service. She also is assistant professor of medicine at Harvard Medical School in Boston. In each of these roles she teaches and mentors hospital residents and medical students, fostering their careers in academia for both research and education.

Through the years, Dr. McKean has received more than a dozen awards for leadership, excellence, and teaching, including the prestigious George W. Thorn Award (1997-1998) from Brigham and Women’s Hospital for outstanding contributions to clinical education. In 2002 she was appointed “scholar” as a charter member of the Harvard Medical School Academy, in recognition of excellence and commitment to improvement and innovation in medical education. Most recently, she was nominated for Harvard Medical School’s 2005 Faculty Prize for Excellence in Teaching.

Dr. McKean’s future vision for hospital medicine education includes the training of hospitalists as leaders and change agents within the hospital system. She emphasizes evidence-based practice, use of multi-disciplinary teams, attention to care transitions, and the importance of doctor-patient communications.

Within SHM, she has fostered many teaching efforts that will advance the knowledge of future hospitalists. As a member of the SHM Core Competencies Task Force, she was a lead author on the nation’s first book outlining core competencies for hospitalists, The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, published in February 2006. This publication is the basis of SHM educational initiatives in the future and provides a roadmap for cultivation of the specialty of hospital medicine, including accreditation.

Dr. McKean also helped SHM develop a series of Web-based quality improvement (QI) resource rooms that feature educational toolkits designed to guide hospitalists step-by-step through the process of implementing a QI program at their institutions. As a clinical expert in venous thromboembolism, she became medical editor of the “Venous Thromboembolism Resource Room” on the SHM Web site and today facilitates the online “VTE Ask the Expert” resource. Dr. McKean also serves as medical editor for SHM’s Web-based, case study CME module titled, “Risk Stratifying for the Development of VTE in the Hospital Setting.”

 

Dr. McKean received her bachelor of arts from Yale University (New Haven, Conn.), completed post baccalaureate science courses at Stanford University, and earned an MD from Dartmouth Medical School (Hanover, N.H.) in 1977. She completed her residency and chief residency training at The New York Hospital and Memorial Sloan Kettering (Cornell Medical Center) in New York City and completed a fellowship in nephrology at The Rogosin Kidney Center, The New York Hospital, New York City.

Dr. Yacovella is assistant professor of medicine at the University of Minnesota Hospitals and Clinic in Minneapolis; section head, Department of Internal Medicine, Regions Hospital in St. Paul; and a practicing hospitalist with HealthPartners Medical Group in St. Paul.

Dr. Yacovella has been recognized throughout his career for his expansive medical knowledge and ability to convey complex medical concepts to his students. He has received more than seven prior distinguished teaching awards from the University of Minnesota Hospital and Clinics in Minneapolis, where he is currently an assistant professor of medicine.

He discovered his love of teaching early in his career as chief resident at St. Paul Ramsey Medical Center (now Regions Hospital) from 1996-1997. He was one of the first hospitalists hired there for what is now a well established, hospitalist program. Many credit the success of the program to Dr. Yacovella.

Dr. Yacovella received his BA in Psychology from the State University of New York at Buffalo in 1989, where he also obtained his MD in 1993. He began his residency program at the University of Minnesota Hospitals and Clinics and was made chief resident at St. Paul Ramsey Medical Center in 1996.

A Preview of the Pediatric Core Curriculum

By Jack Percelay, MD, and David Zipes, MD

Pediatric activity and visibility within SHM has increased over the past several months with increased membership, a focus on the Pediatric Core Competencies, and plans for SHM to sponsor the Pediatric Hospital Medicine Meeting in the summer of 2008.

Approximately 20% of SHM’s new members are pediatricians. Historically, pediatricians number roughly 10% of SHM membership and 10% of hospitalists overall. This increase in pediatric membership is most likely due to a combination of highlighting the value of SHM membership by word of mouth, word of the Listserv, and word of Larry Wellikson as the keynote speaker at the 2005 Pediatric Hospital Medicine Meeting in Denver.

Pediatricians also took advantage of the 2005 productivity survey to generate current benchmarks for pediatric hospitalists. Roughly 15% of returned surveys came from pediatric hospital medicine groups. Initial results will be revealed at this month’s SHM Annual Meeting, and will be available as a benefit to current SHM members through the SHM Web site.

Pediatrics hospitalists were nominated in all four categories of the SHM 2006 Hospital Medicine Awards in 2006. The nominees illustrated the depth and breadth of pediatric hospital medicine programs. Pediatricians Christopher Landrigan, MD, MPH, and Erin Stucky, MD, have been honored as award winners. (See “2006 National Awards of Excellence,” p. 6.)

Pediatric topics continue to appear regularly in The Hospitalist, but as yet there has been no original research published in The Journal of Hospital Medicine. Your contributions are encouraged. Information about submitting topics for either SHM publication is available on the Web site and in the publications themselves.

The current focus of pediatrics within SHM is development of the Pediatric Core Competencies under the leadership of pediatricians Tim Cornell, MD, and Dan Rauch, MD, and SHM Board Member Alpesh Amin, MD, who helped lead the development of the adult core competencies. The core competencies currently include the following proposed clinical, procedural, and systems topics:

 

• Acute abdomen;
• Asthma;
• Apparent life-threatening event;
• Bone and joint infection
• Diabetes;
• Failure to thrive;
• Febrile infant;
• Fluids/electrolytes/nutrition;
• Gastroenteritis;
• Jaundice;
• Kawasaki syndrome;
• Lower respiratory infection;
• Toxic ingestion;
• Meningitis and encephalitis;
• Non-accidental trauma and neglect;
• Pain management;
• Pneumonia;
• Seizure;
• Sickle cell disease complications;
• Soft tissue infection;
• Special technology needs patients;
• Upper respiratory infection; and
• Urinary tract infections.

The style and content of the Pediatric Core Competencies will undergo internal revision and editing before being distributed to external reviewers. Target completion date is the first half of 2007. At this point, we plan to identify appropriate individuals and organizations for the external review process. It would be particularly helpful to identify individuals in lead positions of important organizations (e.g., American Board of Pediatrics), program and clerkship directors, sub-specialty organizations, and so on who have some familiarity with pediatric hospital medicine programs and would be willing to offer a thoughtful critique. The importance of this project cannot be overemphasized. It is the prerequisite for any meaningful discussions for pediatric hospital medicine as a sub-specialty.

Please contact Jack Percelay, MD, (JPercelayMD@yahoo.com) or David Zipes, MD, (dgzipes@indy.rr.com) with any suggestions for or questions about the Pediatric Committee.

SHM Hospital Quality and Patient Safety Committee Update

By Lakshmi Halasyamani, MD

The Health Quality and Patient Safety Committee (HQPSC) is working to represent members at quality improvement forums and create innovate tools and resources to support members in their local QI efforts.

Member Education and Resources

At this year’s SHM Annual Meeting, HQPSC will deliver the pre-course, “High Impact Quality Improvement: How to Ensure a Successful Project,” on May 3 from 8 a.m.-5:30 p.m. The morning session of the pre-course provides in-depth instruction on quality improvement principles and theory. The entire afternoon is devoted to hands-on application of these principles to design and plan local QI programs in one of three areas selected by each participant: glycemic control, VTE prevention, or improving ACE inhibitor/angiotensin receptor blocker (ACEI/ARB) use for heart failure.

The Heart Failure Resource Room recently launched in time for Heart Failure Awareness Week. Visit this Web resource to download a workbook that will guide and support your heart failure-directed QI effort. Learn from an improvement report submitted by Saint Joseph Mercy Hospital in Ann Arbor, Mich., or read or post questions to a panel of heart failure improvement experts.

HQPSC at Large

 

SHM selected Andrew Auerbach, MD, and Greg Maynard, MD, to attend the Assessing the Care of Vulnerable Elders meeting in March. The panel will discuss quality indicators for hospital care, peri-operative care, diabetes, COPD, osteoarthritis, osteoporosis, pressure ulcers, and benign prostatic hyperplasia as they relate to elder care.

The Pay for Performance (P4P) Task Force was recently created to respond to regulatory and legislative initiatives related to P4P. The task force is charged with:

• Educating SHM members on federal P4P initiatives and how they affect hospital medicine, and
• Responding to and formulating SHM position statements and input on P4P programs and legislation.

In the future the HQPSC will review quality indicators proposed by major quality organizations in terms of how relevant they are to hospitalists and hospital medicine. We are working with the SHM Public Policy Committee to ensure that SHM has a representative in the national P4P and quality indicator selection discussion.

JHM Up Close

Barriers and opportunities in caring for the elderly

By Norra MacReady

In 2002 people age 65 years and older accounted for 12% of the population and a whopping 50% of all hospitalizations unrelated to childbirth. The ranks of senior citizens are increasing by 1 million per year in the U.S. and are expected swell to 21% of the population by 2030.

Surprisingly, hospitalists know little about how best to care for the elderly, writes C. Seth Landefeld, MD, in the January/February issue of the Journal of Hospital Medicine. “Hospitalists are good at taking care of acute illnesses like GI bleeding or cardiovascular problems, but they often don’t receive extensive training in problems that occur with aging, like delirium, cognitive impairment, or limitations in mobility,” Dr. Landefeld tells The Hospitalist.

For his article, Dr. Landefeld reviewed the medical literature published since 1980 that covers the course of these patients during and after hospitalization, and he identified gaps in knowledge and treatment strategies.

Clinical trials often include few if any seniors, yet conventional treatments for such common conditions as acute myocardial infarction and delirium may become less effective with age, suggesting that many drugs should be tested in this population.

What’s more, a hospitalized older person is likely to have several comorbidities, as well as cognitive impairment or dementia. As many as one-third of elderly patients have not recovered their baseline function by the time of hospital discharge and can no longer live at home.

There are effective, evidence-based ways to prevent functional disability and delirium—two syndromes common in hospitalized elderly people, writes Dr. Landefeld, who is professor of medicine and chief of the Division of Geriatrics at the University of California, San Francisco. Comprehensive assessment, targeted treatment, and environmental modifications that promote independence and safety can reduce the incidence of both.

All of this could be accomplished with no increase in hospital costs, but several barriers stand in the way, including lack of knowledge about the needs of elderly patients and systems of care that emphasize mechanisms and efficiency over disease management and structured clinical care. Hospitalists trained to maximize outcomes and send patients home as soon as possible may be unaware of the complexity of the issues involved in caring for the very old.

 

“The overall treatment goal is to get the patient back to their original functional level, or at least as well as possible,” says Dr. Landefeld. “When you look at things through that lens, the goal becomes less focused on finding the best antibiotic or anti-thrombolytic, and more on the broader picture of getting the person home.”

Hospitalists and geriatricians should join forces, he adds. At the University of California, San Francisco, they worked together to create the Acute Care for Elders (ACE) units, wards designed for patients who are at least 75. Importantly, nurses play a prominent role in addressing these patient challenges because they are often familiar with the problems these patients have performing simple tasks, such as walking and eating.

UCSF also has established post-discharge clinics—another joint hospitalist-geriatrician venture—where elderly patients can be followed after they leave the hospital. And geriatricians can help hospitalists ensure there are programs in place to let patients make the transition from hospital to home or assisted living as smoothly as possible. TH

This month SHM presents its 2006 national awards of excellence to five hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of patient care and hospital quality improvement across America. The award winners will be recognized at SHM’s 2006 annual meeting in Washington, D.C., on May 5 from 11:35 a.m. to 1:35 p.m. They include:

• Howard Epstein, MD—Award for Clinical Excellence
• Christopher P. Landrigan, MD, MPH—Excellence in Research Award
• Sylvia McKean, MD, FACP—Excellence in Teaching Award
• Erin Ragan Stucky, MD—Award for Outstanding Service in Hospital Medicine
• Thomas J. Yacovella, MD—Excellence in Teaching Award

“SHM is very pleased each year to recognize the hospitalist leaders among us who consistently go above and beyond to champion hospital medicine, to expand the role of hospitalists in areas of patient care and hospital leadership, and to enhance the quality of care, communication, and service we provide,” says Larry Wellikson, CEO of SHM. “These individuals are a true inspiration to us and we congratulate them all for their many accomplishments.”

Dr. Epstein is a recognized leader in the development of clinical excellence and standardization of care in hospital medicine in Minnesota and nationally, and has championed the role of the hospitalist as part of an interdisciplinary team. He currently works with HealthPartners Medical Group at Regions Hospital in St. Paul, Minn., where he is a hospitalist and medical director of the Care Management and Palliative Care Departments. He also is an assistant clinical professor of medicine at the University of Minnesota.

As one of HealthPartners’ first hospitalists, he introduced “Implementation of MCAP Guidelines,” which produced significant improvements in resource utilization. As Regions Hospital’s first medical director for Care Management, he has been instrumental in expanding the role of the Medical Management Steering Committee to routinely incorporate data collection, analysis, and implementation of quality improvement strategies across the care continuum, thus elevating the value of Care Management and enhancing patient care.

Best known for his clinical focus on palliative care, Dr. Esptein established Regions’ Palliative Care Team, the first inpatient program in St. Paul. There he developed a model for palliative care that has improved patient quality of life, eased family suffering, and lessened the use of unnecessary resources at the end of life.

A member of the Institute for Clinical Systems Improvement, a collaborative organization of 57 healthcare organizations and nearly 80% of the physicians in Minnesota, Dr. Epstein has provided leadership in the development of clinical practice guidelines, order sets, healthcare protocols and technology assessments, and the production of standardized, evidence-based hospital order sets used across the state.

A tireless proponent of Hospital Medicine, Dr. Epstein founded the Minnesota Hospitalist Association (now a chapter of SHM) and is a frequent speaker on hospitalists and inpatient palliative care. He currently serves on SHM’s Ethics Committee and Palliative Care Task Force, and will lecture on “The Basic Why and and How to Develop a Hospital-Based Palliative Care Program” on May 5 from 1:35 to 3:05 p.m. at the SHM 2006 Annual Meeting.

Dr. Epstein earned his undergraduate degree and medical degree from Washington University in St. Louis. He completed his residency in internal medicine at the University of Minnesota (Minneapolis) in 1994 and joined the teaching faculty at St. Paul-Ramsey Medical Center (now Regions Hospital) that same year.

Dr. Landrigan has rapidly established himself as one of the nation’s leading investigators in hospital medicine and patient safety, and is a pioneer in academic pediatric hospital medicine. In only a few short years, he has participated in landmark investigative projects, including the establishment of the Pediatric Research in the Inpatient Setting (PRIS) network and the creation of a second textbook for pediatric hospital medicine. The PRIS network is modeled after the American Academy of Pediatrics’ (AAP) successful Pediatric Research in the Outpatient Setting (PROS) network.

 

Dr. Landrigan was the first physician in the United States to complete a fellowship in pediatric hospital medicine, and he focused his research on the future of the field and on evaluating efficiency, quality of care, patient experience, and education in pediatric hospitalist systems. His first published papers helped to define the direction of pediatric hospital medicine.

Dr. Landrigan currently is a pediatric hospitalist at Children’s Hospital Boston, where he is also research director of the Children’s Hospital Inpatient Pediatric Service (CHIPS), and is a pediatric hospitalist fellowship director. At CHIPS, he co-authored one of the first papers to examine medication errors and adverse drug events in the pediatric population, which was published in JAMA (Kaushal R, Bates DW, Landrigan C, et al. Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA. 2001 Apr(285):2114-2120).

Dr. Landrigan also is director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, Boston, and is an assistant professor at Harvard Medical School (Boston). His interest in the role of sleep deprivation in patient safety spurred him to work with a team at Harvard on a project assessing the effects of physician/staff sleep deprivation on patient safety.

As project director of the Harvard Work Hours, Health, and Safety Study, he was lead investigator on an October 2005 New England Journal of Medicine study that demonstrated that interns working industry-sanctioned work schedules with recurrent 30-hour shifts made 36% more serious medical errors, and more than five times as many serious diagnostic errors than interns whose scheduled work was limited to 16 consecutive hours (Pennel NA, Liu JF, Mazzini MJ, et al. Interns’ work hours. N Engl J Med. 2005;352:726-728). This study led to other related studies evaluating the effect of industry-sanctioned work schedules, and sleep deprivation and patient safety, resulting in improvements to the standards.

Dr. Landrigan joined SHM in 1998 as a charter member and has served on the Pediatric Committee since 2002. From 2003-2004 he was also a member of the Research Abstract Committee.

Dr. Landrigan earned his undergraduate degree in 1991 and went on to earn his MD from Mount Sinai Medical School, New York City, and his MPH from Harvard School of Public Health, Boston. He completed his residency in pediatrics at Children’s Hospital Boston and his fellowship in general pediatrics there. He joined the Harvard faculty as instructor in 2000, and was promoted to assistant professor in 2004.

Dr. Stucky is recognized as an innovator in pediatrics and has been one of the nation’s most influential pediatric hospitalists. She has participated in landmark projects advancing pediatric medicine, including the establishment of the PRIS network and the development of the nation’s first pediatric hospital medicine core curriculum program to help define the skills and knowledge base needed for the practice of pediatric hospital medicine.

Dr. Stucky is a pediatric hospitalist at San Diego Children’s Hospital-University of California, where she is also director of the Hospital’s Graduate Medical Education. Dr. Stucky also directs the inpatient teaching service for four area-wide pediatric residency programs, oversees a core lecture series for trainees, and serves on multiple UCSD pediatric residency, intern, and education committees. In conjunction with UCSD, Dr. Stucky also participates in a national collaborative research project with the U.S. Department of Veterans Affairs. As site director for the project, she is finalizing data on medication errors and stress management in hospitalists and residents over a one-year period.

In the public policy arena, Dr. Stucky has distinguished herself as an author and a co-author of a number of policy statements. She was the lead author of the AAP’s policy statement “Prevention of Medication Errors in the Pediatric Inpatient Setting,” which outlines the importance of creating an environment of medication safety. On behalf of the AAP, Dr. Stucky challenged the Joint Council on the Accreditation of Healthcare Organizations (JCAHO) on one of its 2004 national patient safety goals requiring that hospitals caring for neonatal and pediatric patients rapidly eliminate the long-standing “rule of 6” method for administering drug dosages in favor of standardized drip concentrations.

 

Dr. Stucky led a diverse group that convinced JCAHO to develop an alternative proposal. As a result of her persistence, hospitals now have the appropriate time to comply with the new rules.

Because of Dr. Stucky’s clinical credibility and personal collaborative style, she has been successful in co-authoring and completing many controversial policies requiring negotiation and resolution of different interests. She is widely sought after as a reviewer of policies, offering opinions to the Centers for Disease Control and Prevention, Institute of Medicine, and others.

A long-standing member of SHM’s Pediatric Committee, Dr. Stucky has presented an “Update in Pediatric Hospital Medicine” at SHM’s annual meeting for the past three years, and was a plenary speaker at the 2005 tri-sponsored (AAP, the Ambulatory Pediatric Association, and SHM) pediatric hospital medicine conference in Denver—the largest-ever gathering of pediatric hospitalists.

Throughout her career, Dr. Stucky has been the recipient of numerous regional and national awards, including: Best Doctors in America Award (2005); San Diego Magazine’s Best Doctors (2003, 2002); American Academy of Family Physicians “Active Teacher in Family Medicine” Award from the Camp Pendleton Family Practice Program (2002); and the Physician Leadership Award Children’s Hospital (2000).

Dr. Stucky earned her bachelor of science degree in biology from Stanford University and received her MD from the University of California at San Francisco in 1988. She performed her residency at UCSD before becoming chief resident there from 1991-1992.

Dr. McKean is an associate physician in the Division of General Internal Medicine at Brigham and Women’s Hospital, Boston, and is medical director of the Brigham and Women’s and Faulkner Hospitals Hospitalist Service. She also is assistant professor of medicine at Harvard Medical School in Boston. In each of these roles she teaches and mentors hospital residents and medical students, fostering their careers in academia for both research and education.

Through the years, Dr. McKean has received more than a dozen awards for leadership, excellence, and teaching, including the prestigious George W. Thorn Award (1997-1998) from Brigham and Women’s Hospital for outstanding contributions to clinical education. In 2002 she was appointed “scholar” as a charter member of the Harvard Medical School Academy, in recognition of excellence and commitment to improvement and innovation in medical education. Most recently, she was nominated for Harvard Medical School’s 2005 Faculty Prize for Excellence in Teaching.

Dr. McKean’s future vision for hospital medicine education includes the training of hospitalists as leaders and change agents within the hospital system. She emphasizes evidence-based practice, use of multi-disciplinary teams, attention to care transitions, and the importance of doctor-patient communications.

Within SHM, she has fostered many teaching efforts that will advance the knowledge of future hospitalists. As a member of the SHM Core Competencies Task Force, she was a lead author on the nation’s first book outlining core competencies for hospitalists, The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, published in February 2006. This publication is the basis of SHM educational initiatives in the future and provides a roadmap for cultivation of the specialty of hospital medicine, including accreditation.

Dr. McKean also helped SHM develop a series of Web-based quality improvement (QI) resource rooms that feature educational toolkits designed to guide hospitalists step-by-step through the process of implementing a QI program at their institutions. As a clinical expert in venous thromboembolism, she became medical editor of the “Venous Thromboembolism Resource Room” on the SHM Web site and today facilitates the online “VTE Ask the Expert” resource. Dr. McKean also serves as medical editor for SHM’s Web-based, case study CME module titled, “Risk Stratifying for the Development of VTE in the Hospital Setting.”

 

Dr. McKean received her bachelor of arts from Yale University (New Haven, Conn.), completed post baccalaureate science courses at Stanford University, and earned an MD from Dartmouth Medical School (Hanover, N.H.) in 1977. She completed her residency and chief residency training at The New York Hospital and Memorial Sloan Kettering (Cornell Medical Center) in New York City and completed a fellowship in nephrology at The Rogosin Kidney Center, The New York Hospital, New York City.

Dr. Yacovella is assistant professor of medicine at the University of Minnesota Hospitals and Clinic in Minneapolis; section head, Department of Internal Medicine, Regions Hospital in St. Paul; and a practicing hospitalist with HealthPartners Medical Group in St. Paul.

Dr. Yacovella has been recognized throughout his career for his expansive medical knowledge and ability to convey complex medical concepts to his students. He has received more than seven prior distinguished teaching awards from the University of Minnesota Hospital and Clinics in Minneapolis, where he is currently an assistant professor of medicine.

He discovered his love of teaching early in his career as chief resident at St. Paul Ramsey Medical Center (now Regions Hospital) from 1996-1997. He was one of the first hospitalists hired there for what is now a well established, hospitalist program. Many credit the success of the program to Dr. Yacovella.

Dr. Yacovella received his BA in Psychology from the State University of New York at Buffalo in 1989, where he also obtained his MD in 1993. He began his residency program at the University of Minnesota Hospitals and Clinics and was made chief resident at St. Paul Ramsey Medical Center in 1996.

A Preview of the Pediatric Core Curriculum

By Jack Percelay, MD, and David Zipes, MD

Pediatric activity and visibility within SHM has increased over the past several months with increased membership, a focus on the Pediatric Core Competencies, and plans for SHM to sponsor the Pediatric Hospital Medicine Meeting in the summer of 2008.

Approximately 20% of SHM’s new members are pediatricians. Historically, pediatricians number roughly 10% of SHM membership and 10% of hospitalists overall. This increase in pediatric membership is most likely due to a combination of highlighting the value of SHM membership by word of mouth, word of the Listserv, and word of Larry Wellikson as the keynote speaker at the 2005 Pediatric Hospital Medicine Meeting in Denver.

Pediatricians also took advantage of the 2005 productivity survey to generate current benchmarks for pediatric hospitalists. Roughly 15% of returned surveys came from pediatric hospital medicine groups. Initial results will be revealed at this month’s SHM Annual Meeting, and will be available as a benefit to current SHM members through the SHM Web site.

Pediatrics hospitalists were nominated in all four categories of the SHM 2006 Hospital Medicine Awards in 2006. The nominees illustrated the depth and breadth of pediatric hospital medicine programs. Pediatricians Christopher Landrigan, MD, MPH, and Erin Stucky, MD, have been honored as award winners. (See “2006 National Awards of Excellence,” p. 6.)

Pediatric topics continue to appear regularly in The Hospitalist, but as yet there has been no original research published in The Journal of Hospital Medicine. Your contributions are encouraged. Information about submitting topics for either SHM publication is available on the Web site and in the publications themselves.

The current focus of pediatrics within SHM is development of the Pediatric Core Competencies under the leadership of pediatricians Tim Cornell, MD, and Dan Rauch, MD, and SHM Board Member Alpesh Amin, MD, who helped lead the development of the adult core competencies. The core competencies currently include the following proposed clinical, procedural, and systems topics:

 

• Acute abdomen;
• Asthma;
• Apparent life-threatening event;
• Bone and joint infection
• Diabetes;
• Failure to thrive;
• Febrile infant;
• Fluids/electrolytes/nutrition;
• Gastroenteritis;
• Jaundice;
• Kawasaki syndrome;
• Lower respiratory infection;
• Toxic ingestion;
• Meningitis and encephalitis;
• Non-accidental trauma and neglect;
• Pain management;
• Pneumonia;
• Seizure;
• Sickle cell disease complications;
• Soft tissue infection;
• Special technology needs patients;
• Upper respiratory infection; and
• Urinary tract infections.

The style and content of the Pediatric Core Competencies will undergo internal revision and editing before being distributed to external reviewers. Target completion date is the first half of 2007. At this point, we plan to identify appropriate individuals and organizations for the external review process. It would be particularly helpful to identify individuals in lead positions of important organizations (e.g., American Board of Pediatrics), program and clerkship directors, sub-specialty organizations, and so on who have some familiarity with pediatric hospital medicine programs and would be willing to offer a thoughtful critique. The importance of this project cannot be overemphasized. It is the prerequisite for any meaningful discussions for pediatric hospital medicine as a sub-specialty.

Please contact Jack Percelay, MD, (JPercelayMD@yahoo.com) or David Zipes, MD, (dgzipes@indy.rr.com) with any suggestions for or questions about the Pediatric Committee.

SHM Hospital Quality and Patient Safety Committee Update

By Lakshmi Halasyamani, MD

The Health Quality and Patient Safety Committee (HQPSC) is working to represent members at quality improvement forums and create innovate tools and resources to support members in their local QI efforts.

Member Education and Resources

At this year’s SHM Annual Meeting, HQPSC will deliver the pre-course, “High Impact Quality Improvement: How to Ensure a Successful Project,” on May 3 from 8 a.m.-5:30 p.m. The morning session of the pre-course provides in-depth instruction on quality improvement principles and theory. The entire afternoon is devoted to hands-on application of these principles to design and plan local QI programs in one of three areas selected by each participant: glycemic control, VTE prevention, or improving ACE inhibitor/angiotensin receptor blocker (ACEI/ARB) use for heart failure.

The Heart Failure Resource Room recently launched in time for Heart Failure Awareness Week. Visit this Web resource to download a workbook that will guide and support your heart failure-directed QI effort. Learn from an improvement report submitted by Saint Joseph Mercy Hospital in Ann Arbor, Mich., or read or post questions to a panel of heart failure improvement experts.

HQPSC at Large

 

SHM selected Andrew Auerbach, MD, and Greg Maynard, MD, to attend the Assessing the Care of Vulnerable Elders meeting in March. The panel will discuss quality indicators for hospital care, peri-operative care, diabetes, COPD, osteoarthritis, osteoporosis, pressure ulcers, and benign prostatic hyperplasia as they relate to elder care.

The Pay for Performance (P4P) Task Force was recently created to respond to regulatory and legislative initiatives related to P4P. The task force is charged with:

• Educating SHM members on federal P4P initiatives and how they affect hospital medicine, and
• Responding to and formulating SHM position statements and input on P4P programs and legislation.

In the future the HQPSC will review quality indicators proposed by major quality organizations in terms of how relevant they are to hospitalists and hospital medicine. We are working with the SHM Public Policy Committee to ensure that SHM has a representative in the national P4P and quality indicator selection discussion.

JHM Up Close

Barriers and opportunities in caring for the elderly

By Norra MacReady

In 2002 people age 65 years and older accounted for 12% of the population and a whopping 50% of all hospitalizations unrelated to childbirth. The ranks of senior citizens are increasing by 1 million per year in the U.S. and are expected swell to 21% of the population by 2030.

Surprisingly, hospitalists know little about how best to care for the elderly, writes C. Seth Landefeld, MD, in the January/February issue of the Journal of Hospital Medicine. “Hospitalists are good at taking care of acute illnesses like GI bleeding or cardiovascular problems, but they often don’t receive extensive training in problems that occur with aging, like delirium, cognitive impairment, or limitations in mobility,” Dr. Landefeld tells The Hospitalist.

For his article, Dr. Landefeld reviewed the medical literature published since 1980 that covers the course of these patients during and after hospitalization, and he identified gaps in knowledge and treatment strategies.

Clinical trials often include few if any seniors, yet conventional treatments for such common conditions as acute myocardial infarction and delirium may become less effective with age, suggesting that many drugs should be tested in this population.

What’s more, a hospitalized older person is likely to have several comorbidities, as well as cognitive impairment or dementia. As many as one-third of elderly patients have not recovered their baseline function by the time of hospital discharge and can no longer live at home.

There are effective, evidence-based ways to prevent functional disability and delirium—two syndromes common in hospitalized elderly people, writes Dr. Landefeld, who is professor of medicine and chief of the Division of Geriatrics at the University of California, San Francisco. Comprehensive assessment, targeted treatment, and environmental modifications that promote independence and safety can reduce the incidence of both.

All of this could be accomplished with no increase in hospital costs, but several barriers stand in the way, including lack of knowledge about the needs of elderly patients and systems of care that emphasize mechanisms and efficiency over disease management and structured clinical care. Hospitalists trained to maximize outcomes and send patients home as soon as possible may be unaware of the complexity of the issues involved in caring for the very old.

 

“The overall treatment goal is to get the patient back to their original functional level, or at least as well as possible,” says Dr. Landefeld. “When you look at things through that lens, the goal becomes less focused on finding the best antibiotic or anti-thrombolytic, and more on the broader picture of getting the person home.”

Hospitalists and geriatricians should join forces, he adds. At the University of California, San Francisco, they worked together to create the Acute Care for Elders (ACE) units, wards designed for patients who are at least 75. Importantly, nurses play a prominent role in addressing these patient challenges because they are often familiar with the problems these patients have performing simple tasks, such as walking and eating.

UCSF also has established post-discharge clinics—another joint hospitalist-geriatrician venture—where elderly patients can be followed after they leave the hospital. And geriatricians can help hospitalists ensure there are programs in place to let patients make the transition from hospital to home or assisted living as smoothly as possible. TH

This month SHM presents its 2006 national awards of excellence to five hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of patient care and hospital quality improvement across America. The award winners will be recognized at SHM’s 2006 annual meeting in Washington, D.C., on May 5 from 11:35 a.m. to 1:35 p.m. They include:

• Howard Epstein, MD—Award for Clinical Excellence
• Christopher P. Landrigan, MD, MPH—Excellence in Research Award
• Sylvia McKean, MD, FACP—Excellence in Teaching Award
• Erin Ragan Stucky, MD—Award for Outstanding Service in Hospital Medicine
• Thomas J. Yacovella, MD—Excellence in Teaching Award

“SHM is very pleased each year to recognize the hospitalist leaders among us who consistently go above and beyond to champion hospital medicine, to expand the role of hospitalists in areas of patient care and hospital leadership, and to enhance the quality of care, communication, and service we provide,” says Larry Wellikson, CEO of SHM. “These individuals are a true inspiration to us and we congratulate them all for their many accomplishments.”

Dr. Epstein is a recognized leader in the development of clinical excellence and standardization of care in hospital medicine in Minnesota and nationally, and has championed the role of the hospitalist as part of an interdisciplinary team. He currently works with HealthPartners Medical Group at Regions Hospital in St. Paul, Minn., where he is a hospitalist and medical director of the Care Management and Palliative Care Departments. He also is an assistant clinical professor of medicine at the University of Minnesota.

As one of HealthPartners’ first hospitalists, he introduced “Implementation of MCAP Guidelines,” which produced significant improvements in resource utilization. As Regions Hospital’s first medical director for Care Management, he has been instrumental in expanding the role of the Medical Management Steering Committee to routinely incorporate data collection, analysis, and implementation of quality improvement strategies across the care continuum, thus elevating the value of Care Management and enhancing patient care.

Best known for his clinical focus on palliative care, Dr. Esptein established Regions’ Palliative Care Team, the first inpatient program in St. Paul. There he developed a model for palliative care that has improved patient quality of life, eased family suffering, and lessened the use of unnecessary resources at the end of life.

A member of the Institute for Clinical Systems Improvement, a collaborative organization of 57 healthcare organizations and nearly 80% of the physicians in Minnesota, Dr. Epstein has provided leadership in the development of clinical practice guidelines, order sets, healthcare protocols and technology assessments, and the production of standardized, evidence-based hospital order sets used across the state.

A tireless proponent of Hospital Medicine, Dr. Epstein founded the Minnesota Hospitalist Association (now a chapter of SHM) and is a frequent speaker on hospitalists and inpatient palliative care. He currently serves on SHM’s Ethics Committee and Palliative Care Task Force, and will lecture on “The Basic Why and and How to Develop a Hospital-Based Palliative Care Program” on May 5 from 1:35 to 3:05 p.m. at the SHM 2006 Annual Meeting.

Dr. Epstein earned his undergraduate degree and medical degree from Washington University in St. Louis. He completed his residency in internal medicine at the University of Minnesota (Minneapolis) in 1994 and joined the teaching faculty at St. Paul-Ramsey Medical Center (now Regions Hospital) that same year.

Dr. Landrigan has rapidly established himself as one of the nation’s leading investigators in hospital medicine and patient safety, and is a pioneer in academic pediatric hospital medicine. In only a few short years, he has participated in landmark investigative projects, including the establishment of the Pediatric Research in the Inpatient Setting (PRIS) network and the creation of a second textbook for pediatric hospital medicine. The PRIS network is modeled after the American Academy of Pediatrics’ (AAP) successful Pediatric Research in the Outpatient Setting (PROS) network.

 

Dr. Landrigan was the first physician in the United States to complete a fellowship in pediatric hospital medicine, and he focused his research on the future of the field and on evaluating efficiency, quality of care, patient experience, and education in pediatric hospitalist systems. His first published papers helped to define the direction of pediatric hospital medicine.

Dr. Landrigan currently is a pediatric hospitalist at Children’s Hospital Boston, where he is also research director of the Children’s Hospital Inpatient Pediatric Service (CHIPS), and is a pediatric hospitalist fellowship director. At CHIPS, he co-authored one of the first papers to examine medication errors and adverse drug events in the pediatric population, which was published in JAMA (Kaushal R, Bates DW, Landrigan C, et al. Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA. 2001 Apr(285):2114-2120).

Dr. Landrigan also is director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, Boston, and is an assistant professor at Harvard Medical School (Boston). His interest in the role of sleep deprivation in patient safety spurred him to work with a team at Harvard on a project assessing the effects of physician/staff sleep deprivation on patient safety.

As project director of the Harvard Work Hours, Health, and Safety Study, he was lead investigator on an October 2005 New England Journal of Medicine study that demonstrated that interns working industry-sanctioned work schedules with recurrent 30-hour shifts made 36% more serious medical errors, and more than five times as many serious diagnostic errors than interns whose scheduled work was limited to 16 consecutive hours (Pennel NA, Liu JF, Mazzini MJ, et al. Interns’ work hours. N Engl J Med. 2005;352:726-728). This study led to other related studies evaluating the effect of industry-sanctioned work schedules, and sleep deprivation and patient safety, resulting in improvements to the standards.

Dr. Landrigan joined SHM in 1998 as a charter member and has served on the Pediatric Committee since 2002. From 2003-2004 he was also a member of the Research Abstract Committee.

Dr. Landrigan earned his undergraduate degree in 1991 and went on to earn his MD from Mount Sinai Medical School, New York City, and his MPH from Harvard School of Public Health, Boston. He completed his residency in pediatrics at Children’s Hospital Boston and his fellowship in general pediatrics there. He joined the Harvard faculty as instructor in 2000, and was promoted to assistant professor in 2004.

Dr. Stucky is recognized as an innovator in pediatrics and has been one of the nation’s most influential pediatric hospitalists. She has participated in landmark projects advancing pediatric medicine, including the establishment of the PRIS network and the development of the nation’s first pediatric hospital medicine core curriculum program to help define the skills and knowledge base needed for the practice of pediatric hospital medicine.

Dr. Stucky is a pediatric hospitalist at San Diego Children’s Hospital-University of California, where she is also director of the Hospital’s Graduate Medical Education. Dr. Stucky also directs the inpatient teaching service for four area-wide pediatric residency programs, oversees a core lecture series for trainees, and serves on multiple UCSD pediatric residency, intern, and education committees. In conjunction with UCSD, Dr. Stucky also participates in a national collaborative research project with the U.S. Department of Veterans Affairs. As site director for the project, she is finalizing data on medication errors and stress management in hospitalists and residents over a one-year period.

In the public policy arena, Dr. Stucky has distinguished herself as an author and a co-author of a number of policy statements. She was the lead author of the AAP’s policy statement “Prevention of Medication Errors in the Pediatric Inpatient Setting,” which outlines the importance of creating an environment of medication safety. On behalf of the AAP, Dr. Stucky challenged the Joint Council on the Accreditation of Healthcare Organizations (JCAHO) on one of its 2004 national patient safety goals requiring that hospitals caring for neonatal and pediatric patients rapidly eliminate the long-standing “rule of 6” method for administering drug dosages in favor of standardized drip concentrations.

 

Dr. Stucky led a diverse group that convinced JCAHO to develop an alternative proposal. As a result of her persistence, hospitals now have the appropriate time to comply with the new rules.

Because of Dr. Stucky’s clinical credibility and personal collaborative style, she has been successful in co-authoring and completing many controversial policies requiring negotiation and resolution of different interests. She is widely sought after as a reviewer of policies, offering opinions to the Centers for Disease Control and Prevention, Institute of Medicine, and others.

A long-standing member of SHM’s Pediatric Committee, Dr. Stucky has presented an “Update in Pediatric Hospital Medicine” at SHM’s annual meeting for the past three years, and was a plenary speaker at the 2005 tri-sponsored (AAP, the Ambulatory Pediatric Association, and SHM) pediatric hospital medicine conference in Denver—the largest-ever gathering of pediatric hospitalists.

Throughout her career, Dr. Stucky has been the recipient of numerous regional and national awards, including: Best Doctors in America Award (2005); San Diego Magazine’s Best Doctors (2003, 2002); American Academy of Family Physicians “Active Teacher in Family Medicine” Award from the Camp Pendleton Family Practice Program (2002); and the Physician Leadership Award Children’s Hospital (2000).

Dr. Stucky earned her bachelor of science degree in biology from Stanford University and received her MD from the University of California at San Francisco in 1988. She performed her residency at UCSD before becoming chief resident there from 1991-1992.

Dr. McKean is an associate physician in the Division of General Internal Medicine at Brigham and Women’s Hospital, Boston, and is medical director of the Brigham and Women’s and Faulkner Hospitals Hospitalist Service. She also is assistant professor of medicine at Harvard Medical School in Boston. In each of these roles she teaches and mentors hospital residents and medical students, fostering their careers in academia for both research and education.

Through the years, Dr. McKean has received more than a dozen awards for leadership, excellence, and teaching, including the prestigious George W. Thorn Award (1997-1998) from Brigham and Women’s Hospital for outstanding contributions to clinical education. In 2002 she was appointed “scholar” as a charter member of the Harvard Medical School Academy, in recognition of excellence and commitment to improvement and innovation in medical education. Most recently, she was nominated for Harvard Medical School’s 2005 Faculty Prize for Excellence in Teaching.

Dr. McKean’s future vision for hospital medicine education includes the training of hospitalists as leaders and change agents within the hospital system. She emphasizes evidence-based practice, use of multi-disciplinary teams, attention to care transitions, and the importance of doctor-patient communications.

Within SHM, she has fostered many teaching efforts that will advance the knowledge of future hospitalists. As a member of the SHM Core Competencies Task Force, she was a lead author on the nation’s first book outlining core competencies for hospitalists, The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, published in February 2006. This publication is the basis of SHM educational initiatives in the future and provides a roadmap for cultivation of the specialty of hospital medicine, including accreditation.

Dr. McKean also helped SHM develop a series of Web-based quality improvement (QI) resource rooms that feature educational toolkits designed to guide hospitalists step-by-step through the process of implementing a QI program at their institutions. As a clinical expert in venous thromboembolism, she became medical editor of the “Venous Thromboembolism Resource Room” on the SHM Web site and today facilitates the online “VTE Ask the Expert” resource. Dr. McKean also serves as medical editor for SHM’s Web-based, case study CME module titled, “Risk Stratifying for the Development of VTE in the Hospital Setting.”

 

Dr. McKean received her bachelor of arts from Yale University (New Haven, Conn.), completed post baccalaureate science courses at Stanford University, and earned an MD from Dartmouth Medical School (Hanover, N.H.) in 1977. She completed her residency and chief residency training at The New York Hospital and Memorial Sloan Kettering (Cornell Medical Center) in New York City and completed a fellowship in nephrology at The Rogosin Kidney Center, The New York Hospital, New York City.

Dr. Yacovella is assistant professor of medicine at the University of Minnesota Hospitals and Clinic in Minneapolis; section head, Department of Internal Medicine, Regions Hospital in St. Paul; and a practicing hospitalist with HealthPartners Medical Group in St. Paul.

Dr. Yacovella has been recognized throughout his career for his expansive medical knowledge and ability to convey complex medical concepts to his students. He has received more than seven prior distinguished teaching awards from the University of Minnesota Hospital and Clinics in Minneapolis, where he is currently an assistant professor of medicine.

He discovered his love of teaching early in his career as chief resident at St. Paul Ramsey Medical Center (now Regions Hospital) from 1996-1997. He was one of the first hospitalists hired there for what is now a well established, hospitalist program. Many credit the success of the program to Dr. Yacovella.

Dr. Yacovella received his BA in Psychology from the State University of New York at Buffalo in 1989, where he also obtained his MD in 1993. He began his residency program at the University of Minnesota Hospitals and Clinics and was made chief resident at St. Paul Ramsey Medical Center in 1996.

A Preview of the Pediatric Core Curriculum

By Jack Percelay, MD, and David Zipes, MD

Pediatric activity and visibility within SHM has increased over the past several months with increased membership, a focus on the Pediatric Core Competencies, and plans for SHM to sponsor the Pediatric Hospital Medicine Meeting in the summer of 2008.

Approximately 20% of SHM’s new members are pediatricians. Historically, pediatricians number roughly 10% of SHM membership and 10% of hospitalists overall. This increase in pediatric membership is most likely due to a combination of highlighting the value of SHM membership by word of mouth, word of the Listserv, and word of Larry Wellikson as the keynote speaker at the 2005 Pediatric Hospital Medicine Meeting in Denver.

Pediatricians also took advantage of the 2005 productivity survey to generate current benchmarks for pediatric hospitalists. Roughly 15% of returned surveys came from pediatric hospital medicine groups. Initial results will be revealed at this month’s SHM Annual Meeting, and will be available as a benefit to current SHM members through the SHM Web site.

Pediatrics hospitalists were nominated in all four categories of the SHM 2006 Hospital Medicine Awards in 2006. The nominees illustrated the depth and breadth of pediatric hospital medicine programs. Pediatricians Christopher Landrigan, MD, MPH, and Erin Stucky, MD, have been honored as award winners. (See “2006 National Awards of Excellence,” p. 6.)

Pediatric topics continue to appear regularly in The Hospitalist, but as yet there has been no original research published in The Journal of Hospital Medicine. Your contributions are encouraged. Information about submitting topics for either SHM publication is available on the Web site and in the publications themselves.

The current focus of pediatrics within SHM is development of the Pediatric Core Competencies under the leadership of pediatricians Tim Cornell, MD, and Dan Rauch, MD, and SHM Board Member Alpesh Amin, MD, who helped lead the development of the adult core competencies. The core competencies currently include the following proposed clinical, procedural, and systems topics:

 

• Acute abdomen;
• Asthma;
• Apparent life-threatening event;
• Bone and joint infection
• Diabetes;
• Failure to thrive;
• Febrile infant;
• Fluids/electrolytes/nutrition;
• Gastroenteritis;
• Jaundice;
• Kawasaki syndrome;
• Lower respiratory infection;
• Toxic ingestion;
• Meningitis and encephalitis;
• Non-accidental trauma and neglect;
• Pain management;
• Pneumonia;
• Seizure;
• Sickle cell disease complications;
• Soft tissue infection;
• Special technology needs patients;
• Upper respiratory infection; and
• Urinary tract infections.

The style and content of the Pediatric Core Competencies will undergo internal revision and editing before being distributed to external reviewers. Target completion date is the first half of 2007. At this point, we plan to identify appropriate individuals and organizations for the external review process. It would be particularly helpful to identify individuals in lead positions of important organizations (e.g., American Board of Pediatrics), program and clerkship directors, sub-specialty organizations, and so on who have some familiarity with pediatric hospital medicine programs and would be willing to offer a thoughtful critique. The importance of this project cannot be overemphasized. It is the prerequisite for any meaningful discussions for pediatric hospital medicine as a sub-specialty.

Please contact Jack Percelay, MD, (JPercelayMD@yahoo.com) or David Zipes, MD, (dgzipes@indy.rr.com) with any suggestions for or questions about the Pediatric Committee.

SHM Hospital Quality and Patient Safety Committee Update

By Lakshmi Halasyamani, MD

The Health Quality and Patient Safety Committee (HQPSC) is working to represent members at quality improvement forums and create innovate tools and resources to support members in their local QI efforts.

Member Education and Resources

At this year’s SHM Annual Meeting, HQPSC will deliver the pre-course, “High Impact Quality Improvement: How to Ensure a Successful Project,” on May 3 from 8 a.m.-5:30 p.m. The morning session of the pre-course provides in-depth instruction on quality improvement principles and theory. The entire afternoon is devoted to hands-on application of these principles to design and plan local QI programs in one of three areas selected by each participant: glycemic control, VTE prevention, or improving ACE inhibitor/angiotensin receptor blocker (ACEI/ARB) use for heart failure.

The Heart Failure Resource Room recently launched in time for Heart Failure Awareness Week. Visit this Web resource to download a workbook that will guide and support your heart failure-directed QI effort. Learn from an improvement report submitted by Saint Joseph Mercy Hospital in Ann Arbor, Mich., or read or post questions to a panel of heart failure improvement experts.

HQPSC at Large

 

SHM selected Andrew Auerbach, MD, and Greg Maynard, MD, to attend the Assessing the Care of Vulnerable Elders meeting in March. The panel will discuss quality indicators for hospital care, peri-operative care, diabetes, COPD, osteoarthritis, osteoporosis, pressure ulcers, and benign prostatic hyperplasia as they relate to elder care.

The Pay for Performance (P4P) Task Force was recently created to respond to regulatory and legislative initiatives related to P4P. The task force is charged with:

• Educating SHM members on federal P4P initiatives and how they affect hospital medicine, and
• Responding to and formulating SHM position statements and input on P4P programs and legislation.

In the future the HQPSC will review quality indicators proposed by major quality organizations in terms of how relevant they are to hospitalists and hospital medicine. We are working with the SHM Public Policy Committee to ensure that SHM has a representative in the national P4P and quality indicator selection discussion.

JHM Up Close

Barriers and opportunities in caring for the elderly

By Norra MacReady

In 2002 people age 65 years and older accounted for 12% of the population and a whopping 50% of all hospitalizations unrelated to childbirth. The ranks of senior citizens are increasing by 1 million per year in the U.S. and are expected swell to 21% of the population by 2030.

Surprisingly, hospitalists know little about how best to care for the elderly, writes C. Seth Landefeld, MD, in the January/February issue of the Journal of Hospital Medicine. “Hospitalists are good at taking care of acute illnesses like GI bleeding or cardiovascular problems, but they often don’t receive extensive training in problems that occur with aging, like delirium, cognitive impairment, or limitations in mobility,” Dr. Landefeld tells The Hospitalist.

For his article, Dr. Landefeld reviewed the medical literature published since 1980 that covers the course of these patients during and after hospitalization, and he identified gaps in knowledge and treatment strategies.

Clinical trials often include few if any seniors, yet conventional treatments for such common conditions as acute myocardial infarction and delirium may become less effective with age, suggesting that many drugs should be tested in this population.

What’s more, a hospitalized older person is likely to have several comorbidities, as well as cognitive impairment or dementia. As many as one-third of elderly patients have not recovered their baseline function by the time of hospital discharge and can no longer live at home.

There are effective, evidence-based ways to prevent functional disability and delirium—two syndromes common in hospitalized elderly people, writes Dr. Landefeld, who is professor of medicine and chief of the Division of Geriatrics at the University of California, San Francisco. Comprehensive assessment, targeted treatment, and environmental modifications that promote independence and safety can reduce the incidence of both.

All of this could be accomplished with no increase in hospital costs, but several barriers stand in the way, including lack of knowledge about the needs of elderly patients and systems of care that emphasize mechanisms and efficiency over disease management and structured clinical care. Hospitalists trained to maximize outcomes and send patients home as soon as possible may be unaware of the complexity of the issues involved in caring for the very old.

 

“The overall treatment goal is to get the patient back to their original functional level, or at least as well as possible,” says Dr. Landefeld. “When you look at things through that lens, the goal becomes less focused on finding the best antibiotic or anti-thrombolytic, and more on the broader picture of getting the person home.”

Hospitalists and geriatricians should join forces, he adds. At the University of California, San Francisco, they worked together to create the Acute Care for Elders (ACE) units, wards designed for patients who are at least 75. Importantly, nurses play a prominent role in addressing these patient challenges because they are often familiar with the problems these patients have performing simple tasks, such as walking and eating.

UCSF also has established post-discharge clinics—another joint hospitalist-geriatrician venture—where elderly patients can be followed after they leave the hospital. And geriatricians can help hospitalists ensure there are programs in place to let patients make the transition from hospital to home or assisted living as smoothly as possible. TH

Some estimates indicate there are upward of 15,000 hospitalists practicing hospital medicine. And it seems that at any one time 8,000 of them are looking for their first or next job. Most hospital medicine groups are starting up or growing. And with the mobility of our specialty, retention has become as important as recruitment.

SHM has a number of initiatives that can help hospitalists and hospitalist employers sort all this out.

If you are looking for a new opportunity in hospital medicine, your first stop has probably been the extensive recruitment ad pages (“SHM Career Center”) in The Hospitalist. And now SHM has created a unique online “SHM Career Center” that we will match up against CareerBuilder.com or Monster.com for functionality and ease of use. We hope to grow this to be the most extensive collection of hospitalist opportunities anywhere.

Any visitor to the SHM Web site (www.hospitalmedicine.org/careercenter) can view all of the career opportunities and sort through them by setting (academic or community hospital), employer type (hospital or hospitalist group or multispecialty group), and geographic location. You can also look for pediatric or adult-patient hospitalist positions or for full-time or part-time jobs—or even nocturnists.

What’s more, SHM members really can customize their job search at the online “SHM Career Center.” If you belong to SHM you can have jobs e-mailed right to your inbox. You can set your own search parameters, such as “Show me all the jobs where the employer is a hospitalist-only group in Maryland and Pennsylvania.” You can also post a blind resume for potential employers to review and contact you confidentially. Every day just turn on your computer, fire up your e-mail, and there will be jobs waiting for you to investigate.

SHM will also have tips on how to write a resume, how to interview, what you should look for in work hours and compensation, and just about everything you need to find your first job or your next job.

For those hospital medicine groups looking for their next hospitalist, the online “SHM Career Center” will most likely give you the most selected group of hospitalists looking for your job ad. SHM has tried to be the best source to meet the hospitalists’ needs and this is just the next idea we came up with.

Come and give the online “SHM Career Center” a look-see and let us know what you think. Better yet: Become an SHM member and have the jobs come to you.

Career Satisfaction

Once you get that right job, SHM wants to help you make a career in hospital medicine. Every new specialty runs the risk of creating exceptional demands in their early years until everyone figures out just the right formula. Right now SHM has convened a Career Satisfaction Task Force that is conducting research, hosting focus groups, and developing guidelines and parameters to help hospitalists understand what elements lead to the best chance of a satisfying career.

Emergency department physicians went through this in the early days when they went from working 24 shifts a month to 14 to 16 shifts. Pilots developed mandatory work hour restriction to avoid sleepy or stressful situations. We know it feels uncomfortable sometimes to be the pioneer element while things are still in flux. But help is on the way.

 

The good news is that employers are just as concerned about your job satisfaction and preventing burnout as you are (although it may not always seem that way). Many hospital medicine groups and hospitals are realizing that once you find the right hospitalists it takes commitment to retain them and nourish their career. It is expensive and disruptive to have a high turnover in a hospital medicine group. That is why SHM anticipates that many hospitals and hospital medicine groups will want to adopt the conditions that can lead to stability.

In addition to the work of the Career Satisfaction Task Force, the recently released data from the 2005-2006 Hospitalist Compensation and Productivity Survey will be another key element in creating the proper balance of work and pay for hospitalists. This year we had the largest response of hospitalist leaders (and an 85% increase from pediatric hospitalists alone), and SHM believes the current data are the most reliable in defining hospital medicine.

SHM members have access to the complete survey information—either online, on a CD, or in print. Make sure your hospital and your group uses this compensation and productivity gold standard as you make your staffing and compensation decisions.

Young Physicians Have Needs, Too

Obviously most of this is also applicable to physicians in training and in early career, but SHM wants to play an important role in the decision to become a hospitalist and wants to provide the young hospitalist with the skills to succeed. SHM is involved in efforts to redesign internal medicine residencies to make them more applicable to the way medicine is practiced in the 21st century. In the new schema there will be a core of internal medicine that everyone must be competent in. Then there will be an opportunity for individuals to elect to take the latter part of their residency with an emphasis on hospital medicine, a subspecialty, or ambulatory skills. SHM plans to use the recently published SHM Core Competencies in Hospital Medicine as a basis for our efforts in this redesign.

SHM is also developing materials to help medical students and residents understand just what a career in hospital medicine entails. We feel the more the young physicians understand the total picture of hospital medicine the more this will be a sought-after career choice. Hospitalists will have a role in direct patient care, leading change at their hospitals, improving quality, and still be able to have a full life outside of medicine.

The hospital medicine marketplace is still being defined. There is still significant room for growth and mobility. It will be a while before stability settles in. In fact there really is no status quo to use as a benchmark. In all this turbulence, SHM continues to create the tools and resources to help you find a sustainable career in hospital medicine—or to at least help you find your next job. TH

Dr. Wellikson has been CEO of SHM since 2000.

Some estimates indicate there are upward of 15,000 hospitalists practicing hospital medicine. And it seems that at any one time 8,000 of them are looking for their first or next job. Most hospital medicine groups are starting up or growing. And with the mobility of our specialty, retention has become as important as recruitment.

SHM has a number of initiatives that can help hospitalists and hospitalist employers sort all this out.

If you are looking for a new opportunity in hospital medicine, your first stop has probably been the extensive recruitment ad pages (“SHM Career Center”) in The Hospitalist. And now SHM has created a unique online “SHM Career Center” that we will match up against CareerBuilder.com or Monster.com for functionality and ease of use. We hope to grow this to be the most extensive collection of hospitalist opportunities anywhere.

Any visitor to the SHM Web site (www.hospitalmedicine.org/careercenter) can view all of the career opportunities and sort through them by setting (academic or community hospital), employer type (hospital or hospitalist group or multispecialty group), and geographic location. You can also look for pediatric or adult-patient hospitalist positions or for full-time or part-time jobs—or even nocturnists.

What’s more, SHM members really can customize their job search at the online “SHM Career Center.” If you belong to SHM you can have jobs e-mailed right to your inbox. You can set your own search parameters, such as “Show me all the jobs where the employer is a hospitalist-only group in Maryland and Pennsylvania.” You can also post a blind resume for potential employers to review and contact you confidentially. Every day just turn on your computer, fire up your e-mail, and there will be jobs waiting for you to investigate.

SHM will also have tips on how to write a resume, how to interview, what you should look for in work hours and compensation, and just about everything you need to find your first job or your next job.

For those hospital medicine groups looking for their next hospitalist, the online “SHM Career Center” will most likely give you the most selected group of hospitalists looking for your job ad. SHM has tried to be the best source to meet the hospitalists’ needs and this is just the next idea we came up with.

Come and give the online “SHM Career Center” a look-see and let us know what you think. Better yet: Become an SHM member and have the jobs come to you.

Career Satisfaction

Once you get that right job, SHM wants to help you make a career in hospital medicine. Every new specialty runs the risk of creating exceptional demands in their early years until everyone figures out just the right formula. Right now SHM has convened a Career Satisfaction Task Force that is conducting research, hosting focus groups, and developing guidelines and parameters to help hospitalists understand what elements lead to the best chance of a satisfying career.

Emergency department physicians went through this in the early days when they went from working 24 shifts a month to 14 to 16 shifts. Pilots developed mandatory work hour restriction to avoid sleepy or stressful situations. We know it feels uncomfortable sometimes to be the pioneer element while things are still in flux. But help is on the way.

 

The good news is that employers are just as concerned about your job satisfaction and preventing burnout as you are (although it may not always seem that way). Many hospital medicine groups and hospitals are realizing that once you find the right hospitalists it takes commitment to retain them and nourish their career. It is expensive and disruptive to have a high turnover in a hospital medicine group. That is why SHM anticipates that many hospitals and hospital medicine groups will want to adopt the conditions that can lead to stability.

In addition to the work of the Career Satisfaction Task Force, the recently released data from the 2005-2006 Hospitalist Compensation and Productivity Survey will be another key element in creating the proper balance of work and pay for hospitalists. This year we had the largest response of hospitalist leaders (and an 85% increase from pediatric hospitalists alone), and SHM believes the current data are the most reliable in defining hospital medicine.

SHM members have access to the complete survey information—either online, on a CD, or in print. Make sure your hospital and your group uses this compensation and productivity gold standard as you make your staffing and compensation decisions.

Young Physicians Have Needs, Too

Obviously most of this is also applicable to physicians in training and in early career, but SHM wants to play an important role in the decision to become a hospitalist and wants to provide the young hospitalist with the skills to succeed. SHM is involved in efforts to redesign internal medicine residencies to make them more applicable to the way medicine is practiced in the 21st century. In the new schema there will be a core of internal medicine that everyone must be competent in. Then there will be an opportunity for individuals to elect to take the latter part of their residency with an emphasis on hospital medicine, a subspecialty, or ambulatory skills. SHM plans to use the recently published SHM Core Competencies in Hospital Medicine as a basis for our efforts in this redesign.

SHM is also developing materials to help medical students and residents understand just what a career in hospital medicine entails. We feel the more the young physicians understand the total picture of hospital medicine the more this will be a sought-after career choice. Hospitalists will have a role in direct patient care, leading change at their hospitals, improving quality, and still be able to have a full life outside of medicine.

The hospital medicine marketplace is still being defined. There is still significant room for growth and mobility. It will be a while before stability settles in. In fact there really is no status quo to use as a benchmark. In all this turbulence, SHM continues to create the tools and resources to help you find a sustainable career in hospital medicine—or to at least help you find your next job. TH

Dr. Wellikson has been CEO of SHM since 2000.

Some estimates indicate there are upward of 15,000 hospitalists practicing hospital medicine. And it seems that at any one time 8,000 of them are looking for their first or next job. Most hospital medicine groups are starting up or growing. And with the mobility of our specialty, retention has become as important as recruitment.

SHM has a number of initiatives that can help hospitalists and hospitalist employers sort all this out.

If you are looking for a new opportunity in hospital medicine, your first stop has probably been the extensive recruitment ad pages (“SHM Career Center”) in The Hospitalist. And now SHM has created a unique online “SHM Career Center” that we will match up against CareerBuilder.com or Monster.com for functionality and ease of use. We hope to grow this to be the most extensive collection of hospitalist opportunities anywhere.

Any visitor to the SHM Web site (www.hospitalmedicine.org/careercenter) can view all of the career opportunities and sort through them by setting (academic or community hospital), employer type (hospital or hospitalist group or multispecialty group), and geographic location. You can also look for pediatric or adult-patient hospitalist positions or for full-time or part-time jobs—or even nocturnists.

What’s more, SHM members really can customize their job search at the online “SHM Career Center.” If you belong to SHM you can have jobs e-mailed right to your inbox. You can set your own search parameters, such as “Show me all the jobs where the employer is a hospitalist-only group in Maryland and Pennsylvania.” You can also post a blind resume for potential employers to review and contact you confidentially. Every day just turn on your computer, fire up your e-mail, and there will be jobs waiting for you to investigate.

SHM will also have tips on how to write a resume, how to interview, what you should look for in work hours and compensation, and just about everything you need to find your first job or your next job.

For those hospital medicine groups looking for their next hospitalist, the online “SHM Career Center” will most likely give you the most selected group of hospitalists looking for your job ad. SHM has tried to be the best source to meet the hospitalists’ needs and this is just the next idea we came up with.

Come and give the online “SHM Career Center” a look-see and let us know what you think. Better yet: Become an SHM member and have the jobs come to you.

Career Satisfaction

Once you get that right job, SHM wants to help you make a career in hospital medicine. Every new specialty runs the risk of creating exceptional demands in their early years until everyone figures out just the right formula. Right now SHM has convened a Career Satisfaction Task Force that is conducting research, hosting focus groups, and developing guidelines and parameters to help hospitalists understand what elements lead to the best chance of a satisfying career.

Emergency department physicians went through this in the early days when they went from working 24 shifts a month to 14 to 16 shifts. Pilots developed mandatory work hour restriction to avoid sleepy or stressful situations. We know it feels uncomfortable sometimes to be the pioneer element while things are still in flux. But help is on the way.

 

The good news is that employers are just as concerned about your job satisfaction and preventing burnout as you are (although it may not always seem that way). Many hospital medicine groups and hospitals are realizing that once you find the right hospitalists it takes commitment to retain them and nourish their career. It is expensive and disruptive to have a high turnover in a hospital medicine group. That is why SHM anticipates that many hospitals and hospital medicine groups will want to adopt the conditions that can lead to stability.

In addition to the work of the Career Satisfaction Task Force, the recently released data from the 2005-2006 Hospitalist Compensation and Productivity Survey will be another key element in creating the proper balance of work and pay for hospitalists. This year we had the largest response of hospitalist leaders (and an 85% increase from pediatric hospitalists alone), and SHM believes the current data are the most reliable in defining hospital medicine.

SHM members have access to the complete survey information—either online, on a CD, or in print. Make sure your hospital and your group uses this compensation and productivity gold standard as you make your staffing and compensation decisions.

Young Physicians Have Needs, Too

Obviously most of this is also applicable to physicians in training and in early career, but SHM wants to play an important role in the decision to become a hospitalist and wants to provide the young hospitalist with the skills to succeed. SHM is involved in efforts to redesign internal medicine residencies to make them more applicable to the way medicine is practiced in the 21st century. In the new schema there will be a core of internal medicine that everyone must be competent in. Then there will be an opportunity for individuals to elect to take the latter part of their residency with an emphasis on hospital medicine, a subspecialty, or ambulatory skills. SHM plans to use the recently published SHM Core Competencies in Hospital Medicine as a basis for our efforts in this redesign.

SHM is also developing materials to help medical students and residents understand just what a career in hospital medicine entails. We feel the more the young physicians understand the total picture of hospital medicine the more this will be a sought-after career choice. Hospitalists will have a role in direct patient care, leading change at their hospitals, improving quality, and still be able to have a full life outside of medicine.

The hospital medicine marketplace is still being defined. There is still significant room for growth and mobility. It will be a while before stability settles in. In fact there really is no status quo to use as a benchmark. In all this turbulence, SHM continues to create the tools and resources to help you find a sustainable career in hospital medicine—or to at least help you find your next job. TH

Dr. Wellikson has been CEO of SHM since 2000.