Kevin J. O'Leary, MD

Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.

A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]

Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.

We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.

METHODS

A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.

Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.

A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.

Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.

RESULTS

Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).

The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).

Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.

CONCLUSIONS

Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]

Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]

There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.

Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.

Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.

Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.

A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]

Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.

We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.

METHODS

A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.

Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.

A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.

Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.

RESULTS

Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).

The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).

Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.

CONCLUSIONS

Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]

Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]

There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.

Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.

Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.

Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.

A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]

Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.

We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.

METHODS

A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.

Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.

A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.

Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.

RESULTS

Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).

The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).

Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.

CONCLUSIONS

Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]

Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]

There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.

Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.

Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.

An 89‐year‐old female presents to the Emergency Department with lower back pain for the past 5 days. The patient has a past medical history of polymyalgia rheumatica and hypothyroidism. Her medications include prednisone 10 mg daily and levothyroxine 50 g daily. Aside from tenderness over the third lumbar vertebra, her physical exam is unremarkable. An x‐ray shows a fracture of the third lumbar vertebra. Basic laboratory studies, including calcium and creatinine are normal.

The Clinical Problem and Impact

Vertebral fractures (often termed vertebral compression fractures) affect approximately 25% of all postmenopausal women.1, 2 Only one‐third of vertebral fractures are brought to medical attention.3, 4 In the remaining two‐thirds, patients are either asymptomatic or do not seek medical attention. The lifetime risk of a clinical vertebral fracture is approximately 16% and 5% in white women and men, respectively.1 The risk of vertebral fracture increases with age, lower bone mineral density (BMD), and prior vertebral fracture.1, 5 Women with a preexisting vertebral fracture have a 5‐fold increased risk for a new vertebral fracture relative to those without a history of vertebral fracture.5, 6 Approximately 20% of women who sustain a vertebral fracture will have a new vertebral fracture in the subsequent year.5, 6 Vertebral fractures are frequently overlooked on chest x‐rays and hence there is a need for increased awareness and improved recognition of radiographically‐demonstrated fractures.7 Hospitalists must appreciate that a vertebral fracture is often the first clue to underlying osteoporosis. At least 90% of vertebral and hip fractures are attributable to osteoporosis.5

Typically, the pain related to an acute vertebral fracture improves over 4 to 6 weeks.8, 9 However, pain can persist, resulting in functional impairment, and a decline in the quality of life.1013 Vertebral fractures may lead to kyphosis and reduced lung function. This, in turn, may increase the risk for pneumonia, the most common cause of death in patients with osteoporosis.4 Both clinical and subclinical vertebral fractures are, in fact, independently associated with increased mortality,4, 14, 15 particularly in the period immediately following the event.16 The economic impact of osteoporosis and its related fractures is substantial.1719 In 1995, the annual direct medical cost for the inpatient care of vertebral fractures was estimated to be $575 million.19

Evidence‐Based Approach to the Hospitalized Patient

Management

Short Term

Short‐term management goals include the relief of pain and recovery of mobility. Nonsteroidal antiinflammatory drugs (NSAIDs) and low‐dose opioid medications should be used first in an effort to relieve pain. Beyond its potential effect on bone density, calcitonin (Miacalcin, Fortical) has long been used in acute vertebral fractures for analgesia. A systematic review of 5 randomized controlled trials concluded that calcitonin significantly reduced the pain from acute vertebral fractures.27 Calcitonin improved pain as early as 1 week into treatment and the benefit was persistent at 4 weeks. The analgesic mechanism of action for calcitonin is not entirely clear. Proposed mechanisms include increased ‐endorphin release, an antiinflammatory effect, and a direct effect on specific receptors in the central nervous system.27, 28

Pamidronate (Aredia) also has shown efficacy at reducing acute fracture pain. In a double‐blinded trial, Armigeat et al.29 evaluated pamidronate 30 mg daily for 3 days as compared to placebo in 32 patients. Pain scores were improved at 7 and 30 days with pamidronate. The mechanism of analgesia is unclear. Bisphosphonates are known to inhibit osteoclast activity, but may also work by blocking the effect of inflammatory cytokines.29

Early pain relief is critical in order to encourage physical activity. Bed rest should be avoided, as immobility may increase the risk for pressure ulcers, venous thromboembolism, and pneumonia.3033 Although bracing is frequently used in acute vertebral fracture, the modality has not been formally studied. Although also not well studied in the acute setting, physical therapy has been shown to reduce pain and improve functioning for patients with chronic pain from vertebral fracture,34 and is generally recommended.35

Percutaneous vertebral augmentation procedures include vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected through a needle under fluoroscopic guidance into the collapsed vertebral body. With kyphoplasty, balloon tamps are used to elevate vertebral endplates prior to injection of cement (Figure 1).36 The proposed mechanism of action for both procedures is stabilization of the fracture by the hardened polymethylmethacrylate cement. These procedures are commonly performed by interventional radiologists without the need for general anesthesia; however, depending on the institution, they may be done by orthopedic surgeons, neurosurgeons, or anesthesiologists. The procedure can be performed as an outpatient, if indicated. Although the volume of these procedures has grown dramatically in recent years,37, 38 the quality of evidence supporting their use is relatively weak.3941 Only 1 randomized controlled trial has been published evaluating the potential benefit of vertebroplasty over conservative management.42 Voormolen et al.42 evaluated patients with vertebral fractures and pain refractive to 6 weeks of optimal medical therapy. Patients were treated with vertebroplasty or continuation of medical therapy. Vertebroplasty significantly improved pain initially, but not after 2 weeks. Like the study by Voormolen et al.,42 most studies evaluating percutaneous vertebral augmentation procedures have been conducted on patients with long‐term pain refractory to medical management. One notable exception is a nonrandomized trial published by Diamond et al.6 In that study, 55 patients were treated with vertebroplasty while 24 were treated conservatively. Pain at 24 hours was significantly improved in patients treated with vertebroplasty. At 6 weeks, however, there was no difference among the 2 groups.

Figure 1

The risk of short‐term complications from vertebral augmentation procedures is difficult to assess in light of the small sample sizes and methodological limitations of existing studies. Cement leakage occurs in 40% to 41% of patients treated with vertebroplasty, as compared with 8% to 9% with kyphoplasty.39, 41 Pulmonary emboli occur in 0.6% and 0.01% of patients treated with vertebroplasty and kyphoplasty, respectively, while neurologic complications occur in 0.6% and 0.03% of patients.41 Concern exists about whether percutaneous vertebral augmentation procedures might increase the risk for subsequent fractures,43, 44 as the incidence of new fractures appears to be elevated in the period immediately following the procedure and approximately two‐thirds of new fractures occur in vertebrae adjacent to the augmented vertebra.39, 41, 44 However, the 20% incidence of new vertebral fractures in the year following vertebral augmentation is similar to the fracture rate seen in patients not treated with osteoporosis therapy.44

Assessment of the impact of vertebral augmentation procedures on the cost of care is limited by the lack of high‐quality clinical studies.45, 46 Randomized controlled trials evaluating the benefit and risk of these procedures compared to conservative management are underway.4749 Pending further evidence, these procedures are best reserved for patients who fail to benefit from other measures to control pain and improve mobility.

Long Term

A comprehensive discussion of the long‐term management of osteoporosis is beyond the scope of this work. However, the inpatient setting presents an opportune time to initiate long‐term medical therapy. Studies show that the majority of patients who sustain osteoporotic fractures do not receive pharmacologic treatment for osteoporosis.5053 Hospitalists have the opportunity to start medications that can reduce the risk for subsequent fracture by nearly 50%.5458 A total calcium intake of 1200 to 1500 mg per day and vitamin D of 400 to 800 IU per day are recommended for all postmenopausal women. Patients who smoke should receive smoking cessation counseling and be considered for pharmacologic treatment for tobacco dependence. All patients should be assessed for fall risk, including a review of medications and assessment of alcohol intake.

Before considering pharmacologic treatment for osteoporosis, secondary causes of low bone mass must be excluded. Bisphosphonates are generally considered first‐line pharmacologic therapy for osteoporosis. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) have been shown in randomized trials to increase bone density and reduce the risk of osteoporotic fractures.55, 56, 59 Daily, weekly, and monthly preparations of bisphosphonates now exist. Pill‐induced esophagitis is a potential adverse effect of bisphosphonate therapy, but is extremely rare if proper precautions are taken. Patients should take oral bisphosphonates on an empty stomach, with a full glass of water, sitting upright, and have nothing to eat or drink for at least one half hour. If compliance with oral bisphosphonates is not possible, or esophageal abnormalities preclude oral bisphosphonate use, one may consider the use of intravenous ibandronate or zoledronic acid (Reclast). A 3‐year randomized controlled trial of yearly zoledronic acid improved bone density and reduced the incidence of osteoporotic fractures.60 Bisphosphonates are generally not recommended when creatinine clearance is less than 30 mL/minute. Other pharmacologic options for the treatment of osteoporosis include selective estrogen receptor modulators and anabolic agents. The reader is referred to an excellent review by Rosen61 for additional discussion of these therapies. The American College of Rheumatology clinical guidelines for the management of glucocorticoid induced osteoporosis are also worthy of review.62

Hospitalists are naturally suited to improve the quality of care for patients hospitalized with vertebral fractures. Most patients who currently sustain osteoporotic fractures do not receive appropriate evaluation and treatment. One study used an interdisciplinary team to identify, assess, and begin treatment for appropriate patients hospitalized with osteoporotic fractures.63 The intervention resulted in significantly more patients taking osteoporosis treatment medications 6 months after the incident fracture.

Conclusions

Acute vertebral fracture is a common clinical problem associated with significant morbidity and increased risk of mortality. Treatment of vertebral fracture should include analgesics and physical therapy. Percutaneous augmentation procedures may be considered in patients who fail optimal medical therapy. Because most vertebral fractures are due to osteoporosis and the healthcare system currently fails to appropriately assess and treat most patients who have sustained osteoporotic fractures, hospitalists are in an optimal position to initiate long‐term preventative treatment for these patients.

An 89‐year‐old female presents to the Emergency Department with lower back pain for the past 5 days. The patient has a past medical history of polymyalgia rheumatica and hypothyroidism. Her medications include prednisone 10 mg daily and levothyroxine 50 g daily. Aside from tenderness over the third lumbar vertebra, her physical exam is unremarkable. An x‐ray shows a fracture of the third lumbar vertebra. Basic laboratory studies, including calcium and creatinine are normal.

The Clinical Problem and Impact

Vertebral fractures (often termed vertebral compression fractures) affect approximately 25% of all postmenopausal women.1, 2 Only one‐third of vertebral fractures are brought to medical attention.3, 4 In the remaining two‐thirds, patients are either asymptomatic or do not seek medical attention. The lifetime risk of a clinical vertebral fracture is approximately 16% and 5% in white women and men, respectively.1 The risk of vertebral fracture increases with age, lower bone mineral density (BMD), and prior vertebral fracture.1, 5 Women with a preexisting vertebral fracture have a 5‐fold increased risk for a new vertebral fracture relative to those without a history of vertebral fracture.5, 6 Approximately 20% of women who sustain a vertebral fracture will have a new vertebral fracture in the subsequent year.5, 6 Vertebral fractures are frequently overlooked on chest x‐rays and hence there is a need for increased awareness and improved recognition of radiographically‐demonstrated fractures.7 Hospitalists must appreciate that a vertebral fracture is often the first clue to underlying osteoporosis. At least 90% of vertebral and hip fractures are attributable to osteoporosis.5

Typically, the pain related to an acute vertebral fracture improves over 4 to 6 weeks.8, 9 However, pain can persist, resulting in functional impairment, and a decline in the quality of life.1013 Vertebral fractures may lead to kyphosis and reduced lung function. This, in turn, may increase the risk for pneumonia, the most common cause of death in patients with osteoporosis.4 Both clinical and subclinical vertebral fractures are, in fact, independently associated with increased mortality,4, 14, 15 particularly in the period immediately following the event.16 The economic impact of osteoporosis and its related fractures is substantial.1719 In 1995, the annual direct medical cost for the inpatient care of vertebral fractures was estimated to be $575 million.19

Evidence‐Based Approach to the Hospitalized Patient

Management

Short Term

Short‐term management goals include the relief of pain and recovery of mobility. Nonsteroidal antiinflammatory drugs (NSAIDs) and low‐dose opioid medications should be used first in an effort to relieve pain. Beyond its potential effect on bone density, calcitonin (Miacalcin, Fortical) has long been used in acute vertebral fractures for analgesia. A systematic review of 5 randomized controlled trials concluded that calcitonin significantly reduced the pain from acute vertebral fractures.27 Calcitonin improved pain as early as 1 week into treatment and the benefit was persistent at 4 weeks. The analgesic mechanism of action for calcitonin is not entirely clear. Proposed mechanisms include increased ‐endorphin release, an antiinflammatory effect, and a direct effect on specific receptors in the central nervous system.27, 28

Pamidronate (Aredia) also has shown efficacy at reducing acute fracture pain. In a double‐blinded trial, Armigeat et al.29 evaluated pamidronate 30 mg daily for 3 days as compared to placebo in 32 patients. Pain scores were improved at 7 and 30 days with pamidronate. The mechanism of analgesia is unclear. Bisphosphonates are known to inhibit osteoclast activity, but may also work by blocking the effect of inflammatory cytokines.29

Early pain relief is critical in order to encourage physical activity. Bed rest should be avoided, as immobility may increase the risk for pressure ulcers, venous thromboembolism, and pneumonia.3033 Although bracing is frequently used in acute vertebral fracture, the modality has not been formally studied. Although also not well studied in the acute setting, physical therapy has been shown to reduce pain and improve functioning for patients with chronic pain from vertebral fracture,34 and is generally recommended.35

Percutaneous vertebral augmentation procedures include vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected through a needle under fluoroscopic guidance into the collapsed vertebral body. With kyphoplasty, balloon tamps are used to elevate vertebral endplates prior to injection of cement (Figure 1).36 The proposed mechanism of action for both procedures is stabilization of the fracture by the hardened polymethylmethacrylate cement. These procedures are commonly performed by interventional radiologists without the need for general anesthesia; however, depending on the institution, they may be done by orthopedic surgeons, neurosurgeons, or anesthesiologists. The procedure can be performed as an outpatient, if indicated. Although the volume of these procedures has grown dramatically in recent years,37, 38 the quality of evidence supporting their use is relatively weak.3941 Only 1 randomized controlled trial has been published evaluating the potential benefit of vertebroplasty over conservative management.42 Voormolen et al.42 evaluated patients with vertebral fractures and pain refractive to 6 weeks of optimal medical therapy. Patients were treated with vertebroplasty or continuation of medical therapy. Vertebroplasty significantly improved pain initially, but not after 2 weeks. Like the study by Voormolen et al.,42 most studies evaluating percutaneous vertebral augmentation procedures have been conducted on patients with long‐term pain refractory to medical management. One notable exception is a nonrandomized trial published by Diamond et al.6 In that study, 55 patients were treated with vertebroplasty while 24 were treated conservatively. Pain at 24 hours was significantly improved in patients treated with vertebroplasty. At 6 weeks, however, there was no difference among the 2 groups.

Figure 1

The risk of short‐term complications from vertebral augmentation procedures is difficult to assess in light of the small sample sizes and methodological limitations of existing studies. Cement leakage occurs in 40% to 41% of patients treated with vertebroplasty, as compared with 8% to 9% with kyphoplasty.39, 41 Pulmonary emboli occur in 0.6% and 0.01% of patients treated with vertebroplasty and kyphoplasty, respectively, while neurologic complications occur in 0.6% and 0.03% of patients.41 Concern exists about whether percutaneous vertebral augmentation procedures might increase the risk for subsequent fractures,43, 44 as the incidence of new fractures appears to be elevated in the period immediately following the procedure and approximately two‐thirds of new fractures occur in vertebrae adjacent to the augmented vertebra.39, 41, 44 However, the 20% incidence of new vertebral fractures in the year following vertebral augmentation is similar to the fracture rate seen in patients not treated with osteoporosis therapy.44

Assessment of the impact of vertebral augmentation procedures on the cost of care is limited by the lack of high‐quality clinical studies.45, 46 Randomized controlled trials evaluating the benefit and risk of these procedures compared to conservative management are underway.4749 Pending further evidence, these procedures are best reserved for patients who fail to benefit from other measures to control pain and improve mobility.

Long Term

A comprehensive discussion of the long‐term management of osteoporosis is beyond the scope of this work. However, the inpatient setting presents an opportune time to initiate long‐term medical therapy. Studies show that the majority of patients who sustain osteoporotic fractures do not receive pharmacologic treatment for osteoporosis.5053 Hospitalists have the opportunity to start medications that can reduce the risk for subsequent fracture by nearly 50%.5458 A total calcium intake of 1200 to 1500 mg per day and vitamin D of 400 to 800 IU per day are recommended for all postmenopausal women. Patients who smoke should receive smoking cessation counseling and be considered for pharmacologic treatment for tobacco dependence. All patients should be assessed for fall risk, including a review of medications and assessment of alcohol intake.

Before considering pharmacologic treatment for osteoporosis, secondary causes of low bone mass must be excluded. Bisphosphonates are generally considered first‐line pharmacologic therapy for osteoporosis. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) have been shown in randomized trials to increase bone density and reduce the risk of osteoporotic fractures.55, 56, 59 Daily, weekly, and monthly preparations of bisphosphonates now exist. Pill‐induced esophagitis is a potential adverse effect of bisphosphonate therapy, but is extremely rare if proper precautions are taken. Patients should take oral bisphosphonates on an empty stomach, with a full glass of water, sitting upright, and have nothing to eat or drink for at least one half hour. If compliance with oral bisphosphonates is not possible, or esophageal abnormalities preclude oral bisphosphonate use, one may consider the use of intravenous ibandronate or zoledronic acid (Reclast). A 3‐year randomized controlled trial of yearly zoledronic acid improved bone density and reduced the incidence of osteoporotic fractures.60 Bisphosphonates are generally not recommended when creatinine clearance is less than 30 mL/minute. Other pharmacologic options for the treatment of osteoporosis include selective estrogen receptor modulators and anabolic agents. The reader is referred to an excellent review by Rosen61 for additional discussion of these therapies. The American College of Rheumatology clinical guidelines for the management of glucocorticoid induced osteoporosis are also worthy of review.62

Hospitalists are naturally suited to improve the quality of care for patients hospitalized with vertebral fractures. Most patients who currently sustain osteoporotic fractures do not receive appropriate evaluation and treatment. One study used an interdisciplinary team to identify, assess, and begin treatment for appropriate patients hospitalized with osteoporotic fractures.63 The intervention resulted in significantly more patients taking osteoporosis treatment medications 6 months after the incident fracture.

Conclusions

Acute vertebral fracture is a common clinical problem associated with significant morbidity and increased risk of mortality. Treatment of vertebral fracture should include analgesics and physical therapy. Percutaneous augmentation procedures may be considered in patients who fail optimal medical therapy. Because most vertebral fractures are due to osteoporosis and the healthcare system currently fails to appropriately assess and treat most patients who have sustained osteoporotic fractures, hospitalists are in an optimal position to initiate long‐term preventative treatment for these patients.

An 89‐year‐old female presents to the Emergency Department with lower back pain for the past 5 days. The patient has a past medical history of polymyalgia rheumatica and hypothyroidism. Her medications include prednisone 10 mg daily and levothyroxine 50 g daily. Aside from tenderness over the third lumbar vertebra, her physical exam is unremarkable. An x‐ray shows a fracture of the third lumbar vertebra. Basic laboratory studies, including calcium and creatinine are normal.

The Clinical Problem and Impact

Vertebral fractures (often termed vertebral compression fractures) affect approximately 25% of all postmenopausal women.1, 2 Only one‐third of vertebral fractures are brought to medical attention.3, 4 In the remaining two‐thirds, patients are either asymptomatic or do not seek medical attention. The lifetime risk of a clinical vertebral fracture is approximately 16% and 5% in white women and men, respectively.1 The risk of vertebral fracture increases with age, lower bone mineral density (BMD), and prior vertebral fracture.1, 5 Women with a preexisting vertebral fracture have a 5‐fold increased risk for a new vertebral fracture relative to those without a history of vertebral fracture.5, 6 Approximately 20% of women who sustain a vertebral fracture will have a new vertebral fracture in the subsequent year.5, 6 Vertebral fractures are frequently overlooked on chest x‐rays and hence there is a need for increased awareness and improved recognition of radiographically‐demonstrated fractures.7 Hospitalists must appreciate that a vertebral fracture is often the first clue to underlying osteoporosis. At least 90% of vertebral and hip fractures are attributable to osteoporosis.5

Typically, the pain related to an acute vertebral fracture improves over 4 to 6 weeks.8, 9 However, pain can persist, resulting in functional impairment, and a decline in the quality of life.1013 Vertebral fractures may lead to kyphosis and reduced lung function. This, in turn, may increase the risk for pneumonia, the most common cause of death in patients with osteoporosis.4 Both clinical and subclinical vertebral fractures are, in fact, independently associated with increased mortality,4, 14, 15 particularly in the period immediately following the event.16 The economic impact of osteoporosis and its related fractures is substantial.1719 In 1995, the annual direct medical cost for the inpatient care of vertebral fractures was estimated to be $575 million.19

Evidence‐Based Approach to the Hospitalized Patient

Management

Short Term

Short‐term management goals include the relief of pain and recovery of mobility. Nonsteroidal antiinflammatory drugs (NSAIDs) and low‐dose opioid medications should be used first in an effort to relieve pain. Beyond its potential effect on bone density, calcitonin (Miacalcin, Fortical) has long been used in acute vertebral fractures for analgesia. A systematic review of 5 randomized controlled trials concluded that calcitonin significantly reduced the pain from acute vertebral fractures.27 Calcitonin improved pain as early as 1 week into treatment and the benefit was persistent at 4 weeks. The analgesic mechanism of action for calcitonin is not entirely clear. Proposed mechanisms include increased ‐endorphin release, an antiinflammatory effect, and a direct effect on specific receptors in the central nervous system.27, 28

Pamidronate (Aredia) also has shown efficacy at reducing acute fracture pain. In a double‐blinded trial, Armigeat et al.29 evaluated pamidronate 30 mg daily for 3 days as compared to placebo in 32 patients. Pain scores were improved at 7 and 30 days with pamidronate. The mechanism of analgesia is unclear. Bisphosphonates are known to inhibit osteoclast activity, but may also work by blocking the effect of inflammatory cytokines.29

Early pain relief is critical in order to encourage physical activity. Bed rest should be avoided, as immobility may increase the risk for pressure ulcers, venous thromboembolism, and pneumonia.3033 Although bracing is frequently used in acute vertebral fracture, the modality has not been formally studied. Although also not well studied in the acute setting, physical therapy has been shown to reduce pain and improve functioning for patients with chronic pain from vertebral fracture,34 and is generally recommended.35

Percutaneous vertebral augmentation procedures include vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected through a needle under fluoroscopic guidance into the collapsed vertebral body. With kyphoplasty, balloon tamps are used to elevate vertebral endplates prior to injection of cement (Figure 1).36 The proposed mechanism of action for both procedures is stabilization of the fracture by the hardened polymethylmethacrylate cement. These procedures are commonly performed by interventional radiologists without the need for general anesthesia; however, depending on the institution, they may be done by orthopedic surgeons, neurosurgeons, or anesthesiologists. The procedure can be performed as an outpatient, if indicated. Although the volume of these procedures has grown dramatically in recent years,37, 38 the quality of evidence supporting their use is relatively weak.3941 Only 1 randomized controlled trial has been published evaluating the potential benefit of vertebroplasty over conservative management.42 Voormolen et al.42 evaluated patients with vertebral fractures and pain refractive to 6 weeks of optimal medical therapy. Patients were treated with vertebroplasty or continuation of medical therapy. Vertebroplasty significantly improved pain initially, but not after 2 weeks. Like the study by Voormolen et al.,42 most studies evaluating percutaneous vertebral augmentation procedures have been conducted on patients with long‐term pain refractory to medical management. One notable exception is a nonrandomized trial published by Diamond et al.6 In that study, 55 patients were treated with vertebroplasty while 24 were treated conservatively. Pain at 24 hours was significantly improved in patients treated with vertebroplasty. At 6 weeks, however, there was no difference among the 2 groups.

Figure 1

The risk of short‐term complications from vertebral augmentation procedures is difficult to assess in light of the small sample sizes and methodological limitations of existing studies. Cement leakage occurs in 40% to 41% of patients treated with vertebroplasty, as compared with 8% to 9% with kyphoplasty.39, 41 Pulmonary emboli occur in 0.6% and 0.01% of patients treated with vertebroplasty and kyphoplasty, respectively, while neurologic complications occur in 0.6% and 0.03% of patients.41 Concern exists about whether percutaneous vertebral augmentation procedures might increase the risk for subsequent fractures,43, 44 as the incidence of new fractures appears to be elevated in the period immediately following the procedure and approximately two‐thirds of new fractures occur in vertebrae adjacent to the augmented vertebra.39, 41, 44 However, the 20% incidence of new vertebral fractures in the year following vertebral augmentation is similar to the fracture rate seen in patients not treated with osteoporosis therapy.44

Assessment of the impact of vertebral augmentation procedures on the cost of care is limited by the lack of high‐quality clinical studies.45, 46 Randomized controlled trials evaluating the benefit and risk of these procedures compared to conservative management are underway.4749 Pending further evidence, these procedures are best reserved for patients who fail to benefit from other measures to control pain and improve mobility.

Long Term

A comprehensive discussion of the long‐term management of osteoporosis is beyond the scope of this work. However, the inpatient setting presents an opportune time to initiate long‐term medical therapy. Studies show that the majority of patients who sustain osteoporotic fractures do not receive pharmacologic treatment for osteoporosis.5053 Hospitalists have the opportunity to start medications that can reduce the risk for subsequent fracture by nearly 50%.5458 A total calcium intake of 1200 to 1500 mg per day and vitamin D of 400 to 800 IU per day are recommended for all postmenopausal women. Patients who smoke should receive smoking cessation counseling and be considered for pharmacologic treatment for tobacco dependence. All patients should be assessed for fall risk, including a review of medications and assessment of alcohol intake.

Before considering pharmacologic treatment for osteoporosis, secondary causes of low bone mass must be excluded. Bisphosphonates are generally considered first‐line pharmacologic therapy for osteoporosis. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) have been shown in randomized trials to increase bone density and reduce the risk of osteoporotic fractures.55, 56, 59 Daily, weekly, and monthly preparations of bisphosphonates now exist. Pill‐induced esophagitis is a potential adverse effect of bisphosphonate therapy, but is extremely rare if proper precautions are taken. Patients should take oral bisphosphonates on an empty stomach, with a full glass of water, sitting upright, and have nothing to eat or drink for at least one half hour. If compliance with oral bisphosphonates is not possible, or esophageal abnormalities preclude oral bisphosphonate use, one may consider the use of intravenous ibandronate or zoledronic acid (Reclast). A 3‐year randomized controlled trial of yearly zoledronic acid improved bone density and reduced the incidence of osteoporotic fractures.60 Bisphosphonates are generally not recommended when creatinine clearance is less than 30 mL/minute. Other pharmacologic options for the treatment of osteoporosis include selective estrogen receptor modulators and anabolic agents. The reader is referred to an excellent review by Rosen61 for additional discussion of these therapies. The American College of Rheumatology clinical guidelines for the management of glucocorticoid induced osteoporosis are also worthy of review.62

Hospitalists are naturally suited to improve the quality of care for patients hospitalized with vertebral fractures. Most patients who currently sustain osteoporotic fractures do not receive appropriate evaluation and treatment. One study used an interdisciplinary team to identify, assess, and begin treatment for appropriate patients hospitalized with osteoporotic fractures.63 The intervention resulted in significantly more patients taking osteoporosis treatment medications 6 months after the incident fracture.

Conclusions

Acute vertebral fracture is a common clinical problem associated with significant morbidity and increased risk of mortality. Treatment of vertebral fracture should include analgesics and physical therapy. Percutaneous augmentation procedures may be considered in patients who fail optimal medical therapy. Because most vertebral fractures are due to osteoporosis and the healthcare system currently fails to appropriately assess and treat most patients who have sustained osteoporotic fractures, hospitalists are in an optimal position to initiate long‐term preventative treatment for these patients.

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 A potential contributor to this is the inadequate transfer of clinical information at hospital discharge. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings. Unfortunately, discharge summaries are often unavailable at the time of follow‐up care and often lack important content.37

A growing number of hospitals are implementing electronic medical records (EMR). This creates the opportunity to standardize the content of clinical documentation and creates the potential to assemble, immediately at the time of hospital discharge, major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. Previously, we reported the results of a survey of medicine faculty at an urban academic medical center evaluating the timeliness and quality of discharge summaries, the perceived incidence of preventable adverse events related to suboptimal information transfer at discharge, and a needs assessment for an electronically generated discharge summary that we planned to design.8 We now report the results of the follow‐up survey of outpatient physicians and an evaluation of the quality and timeliness of the electronic discharge summary we created.

Materials and Methods

Results

Discussion

Our study found that an electronic discharge summary was well accepted by inpatient physicians and significantly improved the quality and timeliness of discharge summaries. Prior studies have shown that the use of electronically entered discharge summaries improved the timeliness of discharge summaries.1416 However, the discharge summaries used in these studies required manual input of data into a computer system separate from the patient's medical record. To our knowledge, this is the first study to report the impact of discharge summaries generated from an EMR. Leveraging the EMR, we were able to automate the insertion of specific patient data elements, streamline delivery, and create an electronic reminder system to inpatient physicians for summaries not completed 24 hours after discharge.

Prior research has shown that the quality of discharges summaries is improved with the use of standardized content.10, 17 Using a standardized template for the electronic discharge summary, we likewise demonstrated improved quality of discharge summaries. Key discharge summary elements, specifically discussion of follow‐up issues, pending test results, and information provided to the patient and/or family, were present more reliably after the implementation of the electronic discharge summary. The importance of identifying pending test results is underscored by a recent study showing that many patients are discharged from hospitals with test results still pending, and that physicians are often unaware when results are abnormal.18 One discharge summary element, significant laboratory findings, was present less often after the implementation of the electronic discharge summary. Our template did not designate significant laboratory findings under a separate heading. Instead, we used a heading entitled Key Results (labs, imaging, pathology). Physicians completing the discharge summaries may have prioritized the report of imaging and pathology results in this section. A simple revision of our discharge summary template to include a separate heading for significant laboratory findings may result in improvement in this regard.

Timeliness of discharge summaries was improved in our study, but remained less than optimal. Although nearly three‐quarters of electronic discharge summaries were completed within 3 days of discharge, our ultimate goal is to have 100% of discharge summaries completed within 3 days. This is especially important for complicated patients requiring outpatient follow‐up soon after discharge. We are currently in the process of designing further modifications to the electronic discharge summary completion process. One modification that may be beneficial is the automation of additional patient specific data elements into the discharge summary. We also plan to link performance of medication reconciliation, completion of patient discharge instructions, and completion of the discharge summary into an integrated set of activities performed in the EMR prior to patient discharge.

We found that fewer outpatient physicians reported 1 or more of their patients having a preventable adverse event or near miss as a result of suboptimal transfer of information at discharge after the implementation of the electronic discharge summary. Although we did not measure preventable adverse events directly in our study, this is an important finding in light of the large number of patients who sustain preventable adverse events after hospital discharge1, 2 and prior research showing that the absence of discharge summaries at postdischarge follow‐up visits increased the risk for hospital readmission.19

We had wondered what effect the electronic discharge summary would have on the length and clarity of discharge summaries. A published commentary suggested that notes performed in EMRs were inordinately long and often difficult to read.20 We were pleased to discover that electronic discharge summaries were similar in length to previous discharge summaries and were rated higher with regard to clarity.

Our study has several limitations. First, many inpatient physicians began to use electronic discharge summaries prior to our creation of the final electronic discharge summary product. We had explicitly instructed physicians to continue to dictate discharge summaries in the first phase of our study. The fact that physicians quickly adopted the practice of completing discharge summaries electronically suggests that they preferred this method for completion and may help to explain the improvement in timeliness. A second limitation, as previously mentioned, is that our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate the number of their patients discharged in the last 6 months who had sustained a preventable adverse event or near miss related to suboptimal information transfer at discharge. We had limited space in the survey to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Finally, the ordinal scale used to assess clarity of discharge summaries has not been previously validated.

In conclusion, the use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings during the vulnerable period following hospital discharge. As hospitals expand their use of EMRs, they should take advantage of opportunities to leverage functionality to improve quality and timeliness of discharge summaries.

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 A potential contributor to this is the inadequate transfer of clinical information at hospital discharge. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings. Unfortunately, discharge summaries are often unavailable at the time of follow‐up care and often lack important content.37

A growing number of hospitals are implementing electronic medical records (EMR). This creates the opportunity to standardize the content of clinical documentation and creates the potential to assemble, immediately at the time of hospital discharge, major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. Previously, we reported the results of a survey of medicine faculty at an urban academic medical center evaluating the timeliness and quality of discharge summaries, the perceived incidence of preventable adverse events related to suboptimal information transfer at discharge, and a needs assessment for an electronically generated discharge summary that we planned to design.8 We now report the results of the follow‐up survey of outpatient physicians and an evaluation of the quality and timeliness of the electronic discharge summary we created.

Materials and Methods

Results

Discussion

Our study found that an electronic discharge summary was well accepted by inpatient physicians and significantly improved the quality and timeliness of discharge summaries. Prior studies have shown that the use of electronically entered discharge summaries improved the timeliness of discharge summaries.1416 However, the discharge summaries used in these studies required manual input of data into a computer system separate from the patient's medical record. To our knowledge, this is the first study to report the impact of discharge summaries generated from an EMR. Leveraging the EMR, we were able to automate the insertion of specific patient data elements, streamline delivery, and create an electronic reminder system to inpatient physicians for summaries not completed 24 hours after discharge.

Prior research has shown that the quality of discharges summaries is improved with the use of standardized content.10, 17 Using a standardized template for the electronic discharge summary, we likewise demonstrated improved quality of discharge summaries. Key discharge summary elements, specifically discussion of follow‐up issues, pending test results, and information provided to the patient and/or family, were present more reliably after the implementation of the electronic discharge summary. The importance of identifying pending test results is underscored by a recent study showing that many patients are discharged from hospitals with test results still pending, and that physicians are often unaware when results are abnormal.18 One discharge summary element, significant laboratory findings, was present less often after the implementation of the electronic discharge summary. Our template did not designate significant laboratory findings under a separate heading. Instead, we used a heading entitled Key Results (labs, imaging, pathology). Physicians completing the discharge summaries may have prioritized the report of imaging and pathology results in this section. A simple revision of our discharge summary template to include a separate heading for significant laboratory findings may result in improvement in this regard.

Timeliness of discharge summaries was improved in our study, but remained less than optimal. Although nearly three‐quarters of electronic discharge summaries were completed within 3 days of discharge, our ultimate goal is to have 100% of discharge summaries completed within 3 days. This is especially important for complicated patients requiring outpatient follow‐up soon after discharge. We are currently in the process of designing further modifications to the electronic discharge summary completion process. One modification that may be beneficial is the automation of additional patient specific data elements into the discharge summary. We also plan to link performance of medication reconciliation, completion of patient discharge instructions, and completion of the discharge summary into an integrated set of activities performed in the EMR prior to patient discharge.

We found that fewer outpatient physicians reported 1 or more of their patients having a preventable adverse event or near miss as a result of suboptimal transfer of information at discharge after the implementation of the electronic discharge summary. Although we did not measure preventable adverse events directly in our study, this is an important finding in light of the large number of patients who sustain preventable adverse events after hospital discharge1, 2 and prior research showing that the absence of discharge summaries at postdischarge follow‐up visits increased the risk for hospital readmission.19

We had wondered what effect the electronic discharge summary would have on the length and clarity of discharge summaries. A published commentary suggested that notes performed in EMRs were inordinately long and often difficult to read.20 We were pleased to discover that electronic discharge summaries were similar in length to previous discharge summaries and were rated higher with regard to clarity.

Our study has several limitations. First, many inpatient physicians began to use electronic discharge summaries prior to our creation of the final electronic discharge summary product. We had explicitly instructed physicians to continue to dictate discharge summaries in the first phase of our study. The fact that physicians quickly adopted the practice of completing discharge summaries electronically suggests that they preferred this method for completion and may help to explain the improvement in timeliness. A second limitation, as previously mentioned, is that our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate the number of their patients discharged in the last 6 months who had sustained a preventable adverse event or near miss related to suboptimal information transfer at discharge. We had limited space in the survey to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Finally, the ordinal scale used to assess clarity of discharge summaries has not been previously validated.

In conclusion, the use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings during the vulnerable period following hospital discharge. As hospitals expand their use of EMRs, they should take advantage of opportunities to leverage functionality to improve quality and timeliness of discharge summaries.

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 A potential contributor to this is the inadequate transfer of clinical information at hospital discharge. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings. Unfortunately, discharge summaries are often unavailable at the time of follow‐up care and often lack important content.37

A growing number of hospitals are implementing electronic medical records (EMR). This creates the opportunity to standardize the content of clinical documentation and creates the potential to assemble, immediately at the time of hospital discharge, major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. Previously, we reported the results of a survey of medicine faculty at an urban academic medical center evaluating the timeliness and quality of discharge summaries, the perceived incidence of preventable adverse events related to suboptimal information transfer at discharge, and a needs assessment for an electronically generated discharge summary that we planned to design.8 We now report the results of the follow‐up survey of outpatient physicians and an evaluation of the quality and timeliness of the electronic discharge summary we created.

Materials and Methods

Results

Discussion

Our study found that an electronic discharge summary was well accepted by inpatient physicians and significantly improved the quality and timeliness of discharge summaries. Prior studies have shown that the use of electronically entered discharge summaries improved the timeliness of discharge summaries.1416 However, the discharge summaries used in these studies required manual input of data into a computer system separate from the patient's medical record. To our knowledge, this is the first study to report the impact of discharge summaries generated from an EMR. Leveraging the EMR, we were able to automate the insertion of specific patient data elements, streamline delivery, and create an electronic reminder system to inpatient physicians for summaries not completed 24 hours after discharge.

Prior research has shown that the quality of discharges summaries is improved with the use of standardized content.10, 17 Using a standardized template for the electronic discharge summary, we likewise demonstrated improved quality of discharge summaries. Key discharge summary elements, specifically discussion of follow‐up issues, pending test results, and information provided to the patient and/or family, were present more reliably after the implementation of the electronic discharge summary. The importance of identifying pending test results is underscored by a recent study showing that many patients are discharged from hospitals with test results still pending, and that physicians are often unaware when results are abnormal.18 One discharge summary element, significant laboratory findings, was present less often after the implementation of the electronic discharge summary. Our template did not designate significant laboratory findings under a separate heading. Instead, we used a heading entitled Key Results (labs, imaging, pathology). Physicians completing the discharge summaries may have prioritized the report of imaging and pathology results in this section. A simple revision of our discharge summary template to include a separate heading for significant laboratory findings may result in improvement in this regard.

Timeliness of discharge summaries was improved in our study, but remained less than optimal. Although nearly three‐quarters of electronic discharge summaries were completed within 3 days of discharge, our ultimate goal is to have 100% of discharge summaries completed within 3 days. This is especially important for complicated patients requiring outpatient follow‐up soon after discharge. We are currently in the process of designing further modifications to the electronic discharge summary completion process. One modification that may be beneficial is the automation of additional patient specific data elements into the discharge summary. We also plan to link performance of medication reconciliation, completion of patient discharge instructions, and completion of the discharge summary into an integrated set of activities performed in the EMR prior to patient discharge.

We found that fewer outpatient physicians reported 1 or more of their patients having a preventable adverse event or near miss as a result of suboptimal transfer of information at discharge after the implementation of the electronic discharge summary. Although we did not measure preventable adverse events directly in our study, this is an important finding in light of the large number of patients who sustain preventable adverse events after hospital discharge1, 2 and prior research showing that the absence of discharge summaries at postdischarge follow‐up visits increased the risk for hospital readmission.19

We had wondered what effect the electronic discharge summary would have on the length and clarity of discharge summaries. A published commentary suggested that notes performed in EMRs were inordinately long and often difficult to read.20 We were pleased to discover that electronic discharge summaries were similar in length to previous discharge summaries and were rated higher with regard to clarity.

Our study has several limitations. First, many inpatient physicians began to use electronic discharge summaries prior to our creation of the final electronic discharge summary product. We had explicitly instructed physicians to continue to dictate discharge summaries in the first phase of our study. The fact that physicians quickly adopted the practice of completing discharge summaries electronically suggests that they preferred this method for completion and may help to explain the improvement in timeliness. A second limitation, as previously mentioned, is that our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate the number of their patients discharged in the last 6 months who had sustained a preventable adverse event or near miss related to suboptimal information transfer at discharge. We had limited space in the survey to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Finally, the ordinal scale used to assess clarity of discharge summaries has not been previously validated.

In conclusion, the use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings during the vulnerable period following hospital discharge. As hospitals expand their use of EMRs, they should take advantage of opportunities to leverage functionality to improve quality and timeliness of discharge summaries.

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6

Although our study did not find a difference in patient satisfaction with the discharge process, we believe the hospitalistHCC model has the potential to complement efforts to reduce the risk of adverse events as patients transition out of the hospital. It has been reported that 12% of patients have a preventable or ameliorable adverse event in the period immediately following hospital discharge.11, 12 Although Forster et al. did not find a reduction in the risk of adverse events with the addition of a clinical coordinator to a general medical team, they noted incongruence between the coordinator's role and the outcomes measured.6 Similarly, we would need to modify the role of the HCC from a position designed mainly to improve efficiency to one that complements efforts to improve the quality of the discharge process. Possible ways to enhance the HCC role in this regard include increasing the emphasis on and training in patient education skills. Several recently published articles have emphasized the need to redesign the discharge process in an effort to reduce the risk of adverse events following hospital discharge.1315 A modified HCC role might be an essential feature of a redesigned multidisciplinary discharge process.

We were unable to demonstrate improved efficiency for the hospital. Although LOS and cost were lower for patients cared for by the hospitalistHCC teams, the difference was not statistically significant. One possible explanation for why we did not observe a larger reduction in LOS is that our hospitalist service had a lower‐than‐average patient volume during the study period. The lower volume mirrored an unanticipated dip in hospital volume during the same period. Specifically, our service normally discharges an average of 338 patients per month, but during the study period we discharged an average of 235 patients per month. A potential LOS and cost benefit may have been attenuated by the relatively low volume, as hospitalists had ample time to dedicate to communication and coordination of discharge plans.

Our study had several limitations. It was conducted on a nonteaching hospitalist service at a single site. Hospitalist practices vary widely in their staffing and scheduling models. As previously mentioned, we were only able to perform patient satisfaction surveys during the second half of the study period. In addition, hospitalistHCC team patients made up a larger percentage of the patient survey responses (62%) than did control hospitalist patients (38%). This may have affected our ability to detect differences in satisfaction with the hospital discharge process. As also previously noted, our patient volume was lower than normal during the study period. We believe that a higher volume would have magnified differences in hospitalists' perceived efficiency and perhaps resulted in significant improvements in LOS and cost. Finally, the hospital provided funding for only a 12‐week study. This limited our sample size and the power of the study to detect important differences. It is possible that a larger sample size and/or longer study period may have been able to demonstrate a statistically significant improvement in LOS and cost.

Our findings are of particular importance in light of the persistent concerns about hospitalist workload and job satisfaction. Although many hospitalists work with clinical coordinators and case managers, we believe that having the formal structure of a hospitalistcare coordinator team was the key element to improving hospitalist efficiency and satisfaction. We hope that our study is a precursor to research evaluating models of delivering hospital care and their impact on hospitalist work experience, hospital efficiency, and patient outcomes.

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6

Although our study did not find a difference in patient satisfaction with the discharge process, we believe the hospitalistHCC model has the potential to complement efforts to reduce the risk of adverse events as patients transition out of the hospital. It has been reported that 12% of patients have a preventable or ameliorable adverse event in the period immediately following hospital discharge.11, 12 Although Forster et al. did not find a reduction in the risk of adverse events with the addition of a clinical coordinator to a general medical team, they noted incongruence between the coordinator's role and the outcomes measured.6 Similarly, we would need to modify the role of the HCC from a position designed mainly to improve efficiency to one that complements efforts to improve the quality of the discharge process. Possible ways to enhance the HCC role in this regard include increasing the emphasis on and training in patient education skills. Several recently published articles have emphasized the need to redesign the discharge process in an effort to reduce the risk of adverse events following hospital discharge.1315 A modified HCC role might be an essential feature of a redesigned multidisciplinary discharge process.

We were unable to demonstrate improved efficiency for the hospital. Although LOS and cost were lower for patients cared for by the hospitalistHCC teams, the difference was not statistically significant. One possible explanation for why we did not observe a larger reduction in LOS is that our hospitalist service had a lower‐than‐average patient volume during the study period. The lower volume mirrored an unanticipated dip in hospital volume during the same period. Specifically, our service normally discharges an average of 338 patients per month, but during the study period we discharged an average of 235 patients per month. A potential LOS and cost benefit may have been attenuated by the relatively low volume, as hospitalists had ample time to dedicate to communication and coordination of discharge plans.

Our study had several limitations. It was conducted on a nonteaching hospitalist service at a single site. Hospitalist practices vary widely in their staffing and scheduling models. As previously mentioned, we were only able to perform patient satisfaction surveys during the second half of the study period. In addition, hospitalistHCC team patients made up a larger percentage of the patient survey responses (62%) than did control hospitalist patients (38%). This may have affected our ability to detect differences in satisfaction with the hospital discharge process. As also previously noted, our patient volume was lower than normal during the study period. We believe that a higher volume would have magnified differences in hospitalists' perceived efficiency and perhaps resulted in significant improvements in LOS and cost. Finally, the hospital provided funding for only a 12‐week study. This limited our sample size and the power of the study to detect important differences. It is possible that a larger sample size and/or longer study period may have been able to demonstrate a statistically significant improvement in LOS and cost.

Our findings are of particular importance in light of the persistent concerns about hospitalist workload and job satisfaction. Although many hospitalists work with clinical coordinators and case managers, we believe that having the formal structure of a hospitalistcare coordinator team was the key element to improving hospitalist efficiency and satisfaction. We hope that our study is a precursor to research evaluating models of delivering hospital care and their impact on hospitalist work experience, hospital efficiency, and patient outcomes.

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6