Scott A. Flanders

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

BACKGROUND Medication discrepancies are common at hospital discharge and can result in adverse events, hospital readmissions, and emergency department visits. Our objectives were to characterize medication discrepancies at hospital discharge and test the effects of a pharmacist intervention on health care utilization following discharge. METHODS We used a prospective, alternating month quasi-experimental design to compare outcomes of patients receiving the intervention (n = 358) with controls (n = 366). All patients were discharged to home and were at high risk for medication-related problems following discharge because of the number or types of medications they were prescribed, multiple medication changes during hospitalization, or problems managing medications. The intervention consisted of medication therapy assessment, medication reconciliation, screening for adherence concerns, patient counseling and education, and postdischarge telephone follow-up. The primary outcomes were 14-day and 30-day readmission rates and emergency department visits within 72 hours of discharge. Medication discrepancies occurring at discharge were also characterized. RESULTS Medication discrepancies at discharge were identified in 33.5% of intervention patients and 59.6% of control patients (P < .001). Although all discrepancies were resolved in the intervention group prior to discharge, readmission rates did not differ significantly between groups at 14 days (12.6% vs 11.5%; P = .65) and 30 days (22.1% vs 18%; P = .17), nor did emergency department visits (2.8% vs 2.2%, respectively; P = .60). CONCLUSION While our intervention improved the quality of patient discharge by identifying and reconciling medication discrepancies at discharge, there was no effect on postdischarge health care resource utilization.

Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.

Improving health care quality depends on having valid ways to measure quality. Unfortunately, there are few validated quality outcome measurements, because valid and feasible case-mix adjustors are lacking and patients are difficult to follow over time for clinically important outcomes, such as death. Processes of care are easier to identify and measure, but some of these measures will be proven invalid or inappropriate because their scientific rationale was flawed from the start, unanticipated consequences emerge after implementation, or later studies undermine them. We review how these issues played out in the measure of time to first antibiotic dose (TFAD), also called door-to-needle time, for patients presenting to the hospital with community-acquired pneumonia (CAP). We also propose lessons that can be learned from the experience. TFAD as a Quality Measure Community-acquired pneumonia is one of the most common admitting diagnoses in U.S. hospitals, accounting for more than 1 million hospitalizations yearly (1), with short-term mortality rates ranging from 0.5% to 27.1% (2). Given its risk, frequency, and perceived outcome variations, CAP was an obvious candidate for quality measurement and improvement initiatives. Because outcome measurement in CAP was problematic for the usual reasons (data collection burden, case-mix adjustment, and need for posthospital follow-up), investigators sought process measures associated with higher quality. During the 1990s, the notion of time-based quality measures gained favor because evidence emerged that rapid treatment of myocardial infarction, and later trauma, stroke, and sepsis, improved outcomes (37). Naturally, investigators began to examine whether rapid administration of antibiotics might improve CAP outcomes. In 1997, a retrospective study of 14069 Medicare patients hospitalized for CAP found that, after adjustment for severity (2) and demographic factors, administration of antibiotics within 8 hours was associated with a lower 30-day mortality rate (odds ratio [OR], 0.85 [95% CI, 0.75 to 0.96]) (8). Patients were included if they had chest radiography results within 2 days of admission consistent with pneumonia and an initial working diagnosis of pneumonia. In 2004, a second retrospective study of 13771 Medicare patients (age 65 years) hospitalized for CAP (9) also found that, among the 75% of patients without evidence of prehospital receipt of antibiotics, administration of antibiotics within 4 hours was associated with a lower 30-day mortality rate (OR, 0.85 [CI, 0.76 to 0.95]). Extrapolating these data to a hypothetical national Medicare sample, the authors estimated that achieving TFAD by 4 hours after presentation to the hospital would save more than 1200 lives yearly. The 2 studies reported that patients who received their first dose of antibiotics in the first hour of their emergency department stay had a higher mortality rate than those who received antibiotics later; however, this finding was attributed to incomplete adjustment for severity of CAP and was therefore not felt to challenge the main conclusion about TFAD (8, 9). Two smaller studies of CAP found no association between early antibiotic administration and outcomes (10, 11). Nevertheless, the authors of the 2004 study (9) editorialized that the 4-hour TFAD quality measure was still valid (12, 13). Translation into a Performance Standard Almost exclusively on the basis of results from the 1997 study, the Medicare National Pneumonia Project endorsed first antibiotics within 8 hours of hospital arrival as a CAP quality measure in 1998. The Medicare National Pneumonia Project tightened its TFAD window to 4 hours in 2002 on the basis of the prepublication results of the 2004 study by Houck and colleagues (9, 12). In 2003, the Infectious Diseases Society of America (IDSA) also endorsed a 4-hour timeframe (14). With support from the Medicare National Pneumonia Project and IDSA and subsequent endorsement by the National Quality Forum, The Joint Commission and The Centers for Medicare & Medicaid Services (CMS) chose the 4-hour TFAD measure as 1 of their initial core measures of quality (measure PN-5b). Since 2002, this measure has been publicly reported for all U.S. hospitals. In 2006, it became part of a measure set tied to additional payments under several pilot pay-for-performance programs (15). The Response from Emergency Medicine The emergency medicine community began raising red flags about the TFAD measure soon after its formulation, and complaints from this community markedly increased after TFAD was publicly reported and became the subject of pay-for-performance programs (16). Published studies challenging the measure soon followed. Although some questioned the association itself, most focused on the issue of diagnostic uncertainty. One study found that 22% of 86 randomly selected patients with pneumonia had uncertain presentations and often lacked infiltrates on chest radiography, which could have appropriately led to delayed antibiotic administration (17). Another study documented cases that were labeled poor-quality care, in which delayed use of antibiotics was clinically appropriate (18), whereas still another found that maneuvers to improve TFAD were not very cost-effective (19). In fact, many eligible patients with a working diagnosis of CAP who did not receive antibiotics within 4 hours had no radiographic evidence of pneumonia in the emergency department and did not have a final emergency department diagnosis of CAP (20, 21). Moreover, other studies showed that TFAD measurement led to administration of antibiotics in many patients who proved not to have pneumonia or another infectious disease (22, 23). Finally, a recent systematic review concluded that evidence from observational studies fails to confirm decreased mortality with early administration of antibiotics in stable patients with [CAP] (24). On the basis of these studies, analyses, and considerable anecdotal evidence, editorials in the emergency medicine literature argued vigorously for relaxing the TFAD standards (25, 26), pointing out that the measure was skewing emergency department triage priorities and promoting unnecessary antibiotic use (18). The Response from Payers, Regulators, and Professional Societies Within months of the critical publications, The Joint Commission and CMS revisited measure PN-5b. In October 2006, patients eligible for the measure had to have a final emergency department diagnosis of pneumonia (rather than an initial working diagnosis) and objective radiographic findings sometime during the hospitalization. Unfortunately, although the revised criteria solved some of the problems associated with PN-5b, they created new ones. For example, Fee and colleagues (27) worried that the new measures would generate pressure to administer antibiotics before patients were sent for computed tomography to rule out pulmonary embolism (even in the face of nondiagnostic chest radiographs) or to avoid writing pneumonia as the final emergency department diagnosis. In March 2007, IDSA and the American Thoracic Society issued joint guidelines that abolished time-specific goals for CAP treatment, now recommending that patients receive their first dose of antibiotics as soon as possible after a definitive diagnosis of CAP, preferably in the emergency department (28). One month later, The Joint Commission created a test measure (PN-5c) that relaxed the antibiotic administration window to 6 hours. That same month, the National Quality Forum withdrew its endorsement of measure PN-5b and endorsed PN-5c, which became the publicly reported measure in April 2008. In addition, The Joint Commission created a new data element, diagnostic uncertainty, which may exclude patients from TFAD measurement (29, 30). Whether all of these revisions will solve the problems associated with measure PN-5b is unknown; no study has yet shown a benefit from a 6-hour rule, and the diagnostic uncertainty construct has not, to our knowledge, been field-tested and validated. Unanticipated Consequences of TFAD Measurement and Reporting Prompt administration of antibiotics to patients with documented pneumonia makes sense, and seeking ironclad evidence to prove its value might seem to be analogous to requiring proof of the value of parachutes (31). Moreover, a randomized trial that withheld early antibiotic treatment in some patients with CAP would be unethical. It was therefore inevitable that decisions about the timing of antibiotic administration in CAP would be based on imperfect retrospective studies, out of necessity (8, 9). However, the TFAD measure was enacted largely on the evidence derived from 2 large studies, in which conditions (retrospective review of patients with working diagnoses of pneumonia) replicate only in part the predicament that busy emergency medicine physicians face daily: evaluating scores of patients with cough, fever, dyspnea, weakness, dizziness, confusion, or abdominal pain. As Pines (26) has written, Most ED [emergency department] patients do not present at triage with a sign on their forehead that reads, I have pneumonia; give me antibiotics now! Unlike myocardial infarction, in which there is palpable clinical urgency to confirm the diagnosis and a series of tests (cardiac biomarker measurement and electrocardiography) available to reliably do so, no gold standard test for pneumonia exists. Although a triage rule of obtaining an electrocardiogram in any patient whose symptoms, signs, or risk factors make myocardial infarction even a remote possibility makes perfect sense, a similar strategy for chest radiography would be resource intensive, often confusing (given the relatively poor sensitivity and specificity of the test in CAP [32]), impractical, and even potentially harmful (because of radiation exposure). In the days before measurement of TFAD, patients with uncertain diagnoses would continue to be evaluated until th

Identifying patients with severe sepsis using administrative claims: Patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis

Background:Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called “Angus” implementation. Methods:Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009–2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by 3 internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists’ summary clinical judgment on whether the patient had severe sepsis. Results:Three thousand one hundred forty-six (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (Angus-positive) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a &kgr; of 0.70. The Angus implementation’s positive predictive value was 70.7% [95% confidence interval (CI): 51.2%, 90.5%]. The negative predictive value was 91.5% (95% CI: 79.0%, 100%). The sensitivity was 50.4% (95% CI: 14.8%, 85.7%). Specificity was 96.3% (95% CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high positive predictive values but sensitivities of <20%. Conclusions:The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.

Triggers of Hospitalization for Venous Thromboembolism

Background— The rate of hospitalization for venous thromboembolism (VTE) is increasing in the United States. Although predictors of hospital-acquired VTE are well-known, triggers of VTE before hospitalization are not as clearly defined. The objective of this study was to evaluate triggers of hospitalization for VTE. Methods and Results— A case-crossover study was conducted. Subjects were participants in the Health and Retirement Study, a nationally representative sample of older Americans. Data were linked to Medicare files for hospital and nursing home stays, emergency department visits, outpatient visits including physician visits, and home health visits from years 1991 to 2007 (n=16 781). The outcome was hospitalization for venous thromboembolism (n=399). Exposures during the 90-day period before hospitalization for VTE were compared with exposures occurring in 4 comparison periods. Infection was the most common trigger of hospitalization for VTE, occurring in 52.4% of the risk periods before hospitalization. The adjusted incidence rate ratios (IRRs; 95% confidence interval) were 2.90 (2.13, 3.94) for all infection, 2.63 (1.90, 3.63) for infection without a previous hospital or skilled nursing facility stay, and 6.92 (4.46, 10.72) for infection with a previous hospital or skilled nursing facility stay. Erythropoiesis-stimulating agents and blood transfusion were also associated with VTE hospitalization (IRR=9.33, 95% confidence interval: 1.19, 73.42; IRR=2.57, 95% confidence interval: 1.17, 5.64; respectively). Other predictors included major surgeries, fractures (IRR=2.81), immobility (IRR=4.23), and chemotherapy (IRR=5.70). These predictors, combined, accounted for a large proportion (69.7%) of exposures before VTE hospitalization as opposed to 35.3% in the comparison periods. Conclusions— Risk prediction algorithms for VTE should be reevaluated to include infection, erythropoiesis-stimulating agents, and blood transfusion.

The Problem With Peripherally Inserted Central Catheters

CENTRAL VENOUS CATHETERS (CVCS) PROVIDE REliable venous access for tasks as diverse as delivery of medication, laboratory testing, and hemodynamic monitoring and occupy a fundamental role in the management of seriously ill patients. However, despite their many benefits, CVCs are not innocuous and are associated with important complications. Among these, central line–associated bloodstream infection (CLABSI) and venous thromboembolism are significant because they are difficult to detect, increase the cost of care, and are potentially life-threatening adverse events. Consequently, studies to predict and prevent these complications have become a research priority. Because of the frequent use of CVCs in the intensive care unit (ICU), efforts to reduce these unfavorable outcomes have traditionally focused on critically ill patients, a population for which substantial progress has been made. For example, improvements in measurement of infectious episodes by standardized definitions and diffusion of evidence-based practices have led to a 58% decrease in CLABSI in ICUs across the United States. Similarly, evidence-based guidelines emphasizing risk estimation and pharmacological prophylaxis have decreased the risk of CVC-related venous thromboembolism in ICU patients. Important shifts in the epidemiology of CVCs from ICU to non-ICU settings, however, may threaten this progress. For instance, in a survey involving 2459 patients in 6 medical centers, the majority of CVCs (70%) were being used in non-ICU patients. Furthermore, CVCs remain in place for longer durations when inserted in non-ICU settings, theoretically increasing the risk of CLABSI and venous thromboembolism. Recent data confirm this concern: of the 9826 CLABSIs reported by participating National Healthcare Safety Network hospitals in 2010, 31% occurred in non-ICU patients. In a study seeking to simplify the estimation of venous thrombosis risk in hospitalized patients, the presence of a CVC was among 4 of the strongest risk factors associated with venous thromboembolism. These findings are all the more concerning because lack of comprehensive surveillance for CLABSI in some non-ICU settings, absence of a homogenous patient and clinician population in contrast to those within ICUs, and controversies regarding venous thromboembolism prophylaxis represent major barriers to prevention in non-ICU settings. Peripherally inserted central catheters (PICCs) are venous catheters that are inserted peripherally, and terminate in central veins such that they may be categorized as CVCs. For multiple reasons, PICCs have become among the most frequently encountered CVC in non-ICU patients. For instance, these devices are safer to insert than CVCs, eliminate the discomfort associated with phlebotomy and scheduled peripheral intravenous line changes, and provide extended and reliable venous access. Because specially trained nurses commonly place PICCs at the patient’s bedside, ready access to these devices has increased. Furthermore, because PICCs reduce cost by enabling earlier hospital discharge through home intravenous therapy, payers have welcomed and supported the widespread use of these venous catheters. These logistical factors notwithstanding, a key factor contributing to increasing PICC use is the perception that they are safer than CVCs with respect to important complications. Initial studies found PICC-related bloodstream infection rates were significantly lower than rates associated with CVCs. However, accumulating evidence suggests that the risk of PICC-related complications is not uniform. For example, Ajenjo et al reported that PICC-related CLABSI was almost twice as likely for PICCs that were inserted in ICU settings compared with non-ICU settings (4.79 vs 2.79 episodes per 1000 catheter-days, respectively; relative risk, 1.70 [95% CI, 1.10–2.61]). With respect to venous thromboembolism, factors such as site of PICC insertion (right or left arm), number of PICC lumens, the position of the PICC tip, and patient characteristics such as malignancy, prior venous thromboembolism, or both, interact to influence risk of thrombosis. Taken together, these data suggest that the risk of CLABSI and venous thromboembolism associated with PICCs is dynamic and varies according to

Is Statin Use Associated with Reduced Mortality After Pneumonia? A Systematic Review and Meta-analysis

OBJECTIVE The objective of this study was to perform a systematic review and meta-analysis of the effects of statins on mortality following pneumonia. METHODS We searched MEDLINE, EMBASE, BIOSIS, Cochrane CENTRAL Register of Controlled Trials, Cambridge Scientific Abstracts, BIOSIS, and Scopus. Studies were included if they involved: participants ≥18 years of age; patients with community-acquired pneumonia; current statin users; and reported overall or adjusted mortality after pneumonia. RESULTS Of 491 citations identified, 13 studies involving 254,950 patients met eligibility criteria. Pooled unadjusted data showed that statin use was associated with lower mortality after pneumonia (odds ratio [OR] 0.62, 95% confidence interval [CI], 0.54-0.71). Pooling of adjusted data also showed reduced mortality after pneumonia (OR 0.66, 95% CI, 0.55-0.79). However, this effect was attenuated in subgroup analysis by confounders and in prospective studies. CONCLUSIONS Although statin use is associated with decreased mortality after pneumonia, this effect weakens in important subgroups. Only a randomized controlled study can fully explore the link between statins and pneumonia mortality.

The epidemiology of acute organ system dysfunction from severe sepsis outside of the intensive care unit.

BACKGROUND Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU. OBJECTIVE To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non-ICU services. DESIGN Retrospective cohort study. SETTING A large, tertiary, academic medical center in the United States. PATIENTS Adult patients initially admitted to non-ICU medical services from 2009 through 2010. MEASUREMENTS All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis. RESULTS Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases. CONCLUSIONS Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.

In the clinic transitions of care

Section Editors Deborah Cotton, MD, MPH Darren Taichman, MD, PhD Sankey Williams, MD The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge and SelfAssessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org, http://www.acponline.org/products_services/ mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

Hospitalists in teaching hospitals: opportunities but not without danger.

One thing seems clear: hospitalists do not appear to be going away. After Wachter and Goldman first used the term hospitalist to describe a new type of U.S. physician 8 years ago,1 the concept of hospital medicine was not warmly embraced by all.2–4 Even at the 1999 Society of General Internal Medicines 22nd annual meeting in San Francisco, more than a few boos were heard when the topic of hospitalists came up. Hospital medicine is now one of the fastest growing medical “specialties” in the United States. The Society of Hospital Medicine, the national organization that represents hospitalists, boasts upward of 3,500 members. The number of want ads in the New England Journal of Medicine and Annals of Internal Medicine for hospitalists rivals those for primary care-based internists. Medical residents seem genuinely excited to enter the field of hospital medicine because they often consider being a hospitalist almost like being a subspecialist but without the required several years of subspecialty fellowship (subspecialist-lite). Even some graduates of primary care residencies are choosing to become hospitalists rather than office-based internists.5 Teaching hospitals have adopted the hospital medicine model to suit their needs. Among the most famous academic medical centers, most actually had a form of hospitalist care even before the recent advent of hospitalists. Many of us can remember the 1 month-per-year attendings who would emerge from their basic science laboratories to attend on the wards for a few weeks. Often these distinguished scientists provided limited clinical input or teaching related to the patient care issues that arose on a daily basis. A handful, perhaps, should even have been offered continuing medical education credit for the month. Interestingly, most residents did not mind this model because it allowed them great autonomy in patient care. During the 1990s, however, teaching hospitals were under increasing pressure from payers and government agencies to modify the way they cared for inpatients. These changes, along with the practice-makes-perfect argument, provided much of the catalyst for the rising number of hospitalists within the walls of teaching hospitals. A major paradigm shift has recently occurred, one that has the opportunity of solidifying the role of hospitalists in teaching hospitals. As of July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) has imposed new requirements restricting resident duty hours.6 As teaching hospitals have learned that not all members of their medical staffs are either interested in or capable of caring for patients without a resident buffer, they are turning toward hospitalists as the solution to the residency work duty problem. One approach is to “uncover” patients so that the hospitalist cares for the patient without resident involvement. In fact, the majority of hospitals listed as U.S. News and World Reports Best Hospitals either have developed or are developing such a “hospitalist-only” service. What about the hospitalist educators role within teaching hospitals? The study by Kulaga et al.7 in this issue of the Journal of General Internal Medicine sheds light on this issue. The authors found that hiring two hospitalist educators at their community-based teaching hospital led to decreased resource utilization and improved resident education when compared to having private physicians manage hospitalized patients.7 Enhanced efficiency due to hospitalists has been demonstrated in several previous studies, in both community and academic settings.8 The finding of an educational benefit for hospitalists in a community teaching hospital, however, is relatively new. Others have found that hospitalists improve resident learning and satisfaction in academic medical centers,9,10 and that hospitalists provide positive, and perhaps improved, experiences for medical students at academic medical centers.11 The limited number of studies evaluating this phenomenon notwithstanding, the reason underlying the educational benefit of hospitalists should surprise few. Most hospitalists hired at teaching hospitals are chosen because they are known to possess superior clinical and educational skills. While the prehospitalists clinical efficiency (in terms of resource utilization) is rarely known during residency, residency program directors are acutely aware of the residents inpatient abilities with regard to teaching, medical decision making, leadership, and navigating a patient through the increasingly complex inpatient environment. We would even venture that if the person hiring hospitalists at a teaching hospital finds that these individuals are not among their institutions top clinician educators, they need look no farther than the mirror to assign blame. What does the rise of hospital medicine within teaching hospitals portend for the future? We’ll put our collective nickel down. We believe that because of the ACGME duty hour restrictions more teaching hospitals will move toward developing “resident-free” inpatient services. We believe that hospitalists will be the providers who are primarily hired by these teaching hospitals to provide direct patient care (lets call them “capital H” Hospitalists). Furthermore, Hospitalist Educators (capital H and capital E)—who will attend anywhere between 3 and 6 months a year—will continue to have a major role in patient care as well as house officer and medical student education. Similar studies to the one appearing in this months Journal7 will likely continue to reveal the educational advantages of hospitalists, thereby spurring more teaching hospitals to hire their former star residents to attend on the wards. These new opportunities for hospitalists are considerable but do not come without danger. As hospitalists are increasingly utilized to provide care for nonresident services in academic medical centers, the potential exists for these faculty members to be seen primarily as “superresidents.” In many academic centers, they will be the only faculty members who manage hospitalized patients without the assistance of either residents or fellows. If clinical care is the only tangible responsibility of hospitalists in the teaching hospital, we fear they will be perceived as second-class members of the academic community. Therefore, staffing a non-house staff service should not come at the expense of visible teaching roles. Hospitalist involvement in several educational activities—such as didactic medical student education, hospitalist electives for fourth-year medical students, hospitalist residency tracks for internal medicine house officers, and training of allied health professionals—are compatible with also staffing a non-house staff service. Because hospitalists will ultimately be evaluated primarily by their contributions to medical education and inpatient-oriented research, emphasizing only efficient, non-house staff clinical care will likely result in an unfavorable judgment by the academic community. Indeed, the experience of other new specialties—such as emergency medicine and critical care—has revealed that in addition to filling a clinical niche, successful specialties also must develop robust training programs and research agendas.12 Thus, like others, we believe that much of hospital medicines future in teaching hospitals—especially within large academic medical centers—will depend on developing a vigorous hospitalist-led clinical research agenda.13,14 The current small cadre of hospitalist investigators (who spend the bulk of their time pursuing scholarly endeavors) will undoubtedly grow and focus on all aspects of inpatient care. The lasting impact of hospital medicine at academic medical centers depends heavily upon this group. Finally, as the hospital medicine model matures, hospitalist administrators will be chosen not only to run hospitalist programs but also to perform vital duties within the hospital such as chairing important committees (e.g., patient safety, pharmaceutical, and therapeutics). Eventually, hospitalists will likely rise to the ranks of chief operating officer, chief of staff, or chief medical officer in their respective organizations. The reason is simple—these are likely to be individuals who are well regarded clinically and viewed as first-rate educators, and, importantly, know how the hospital works. The table is set. All the ingredients are at hand. The external forces—the marketplace, regulatory bodies, and cost pressures—seem to be aligned. The early data appear promising. Only one thing remains: a tincture of time.

Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism : A Cohort Study

IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients. MAIN OUTCOMES AND MEASURES Association between hospital performance and time to development of VTE within 90 days of hospital admission. RESULTS A total of 14 563 of 20 794 patients (70.0%) eligible for pharmacologic prophylaxis received prophylaxis on admission. The rates of pharmacologic prophylaxis use at hospitals in the high-, moderate-, and low-performance tertiles were 85.8%, 72.6%, and 55.5%, respectively. A total of 226 VTE events occurred during 1 765 449 days of patient follow-up. Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders. Results remained robust when examining mechanical prophylaxis, prophylaxis use throughout the hospitalization, and subsequent inpatient stays after discharge from the index hospitalization. CONCLUSIONS AND RELEVANCE The occurrence of 90-day VTE in medical patients after hospitalization is low. Patients who receive care at hospitals that have lower rates of pharmacologic prophylaxis do not have higher adjusted hazards of VTE, even after accounting for individual receipt of pharmacologic prophylaxis. Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome.