Clinical question: What are the incidence, recurrence rate, and mortality rate of Clostridium difficile infection (CDI) in the U.S. in 2011?

Background: CDI has continued to change, and its impact on healthcare has continued to increase.

Study design: Cross-sectional analysis.

Setting: U.S.

Synopsis: The incidence, rate of recurrence, and rate of mortality of C. diff were estimated using 10 sites from the CDC Emerging Infections Program. C. diff incidence was estimated at 453,000 cases, with higher rates among females, whites, and those over age 65. One-third of the cases were community associated. There were an estimated 83,000 first-time recurrent infections and 29,300 estimated deaths within 30 days of diagnosis, with half of those deaths attributable to CDI itself.

This study was limited by the reliance of the case definition solely on positive test results and the trend of labs transitioning to nucleic acid amplification testing (NAAT), both of which can lead to inclusion of colonization (not just actual disease). Also, the recurrence and mortality rates were underestimated, because the study only included first-time recurrences and deaths that were documented in the medical record.

Bottom line: C. diff caused nearly half a million infections and was associated with roughly 29,000 deaths in the U.S. in 2011.

Citation: Less FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372:825-834.

Clinical question: What are the incidence, recurrence rate, and mortality rate of Clostridium difficile infection (CDI) in the U.S. in 2011?

Background: CDI has continued to change, and its impact on healthcare has continued to increase.

Study design: Cross-sectional analysis.

Setting: U.S.

Synopsis: The incidence, rate of recurrence, and rate of mortality of C. diff were estimated using 10 sites from the CDC Emerging Infections Program. C. diff incidence was estimated at 453,000 cases, with higher rates among females, whites, and those over age 65. One-third of the cases were community associated. There were an estimated 83,000 first-time recurrent infections and 29,300 estimated deaths within 30 days of diagnosis, with half of those deaths attributable to CDI itself.

This study was limited by the reliance of the case definition solely on positive test results and the trend of labs transitioning to nucleic acid amplification testing (NAAT), both of which can lead to inclusion of colonization (not just actual disease). Also, the recurrence and mortality rates were underestimated, because the study only included first-time recurrences and deaths that were documented in the medical record.

Bottom line: C. diff caused nearly half a million infections and was associated with roughly 29,000 deaths in the U.S. in 2011.

Citation: Less FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372:825-834.

Clinical question: What are the incidence, recurrence rate, and mortality rate of Clostridium difficile infection (CDI) in the U.S. in 2011?

Background: CDI has continued to change, and its impact on healthcare has continued to increase.

Study design: Cross-sectional analysis.

Setting: U.S.

Synopsis: The incidence, rate of recurrence, and rate of mortality of C. diff were estimated using 10 sites from the CDC Emerging Infections Program. C. diff incidence was estimated at 453,000 cases, with higher rates among females, whites, and those over age 65. One-third of the cases were community associated. There were an estimated 83,000 first-time recurrent infections and 29,300 estimated deaths within 30 days of diagnosis, with half of those deaths attributable to CDI itself.

This study was limited by the reliance of the case definition solely on positive test results and the trend of labs transitioning to nucleic acid amplification testing (NAAT), both of which can lead to inclusion of colonization (not just actual disease). Also, the recurrence and mortality rates were underestimated, because the study only included first-time recurrences and deaths that were documented in the medical record.

Bottom line: C. diff caused nearly half a million infections and was associated with roughly 29,000 deaths in the U.S. in 2011.

Citation: Less FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372:825-834.

Clinical question: Does CT angiography (CTA) improve clinical outcomes in patients with new-onset stable chest pain more than functional testing?

Background: Chest pain is a common clinical problem, and multiple noninvasive tests are available to detect coronary artery disease (CAD). CT angiography is more accurate than noninvasive testing and may decrease unnecessary invasive testing and improve outcomes in patients with new-onset stable chest pain.

Study design: Pragmatic, comparative-effectiveness design.

Setting: One hundred ninety-three North American sites.

Synopsis: Ten thousand three symptomatic outpatients, mean age 60 years, with at least one cardiovascular risk factor, were randomized to CTA or functional testing to detect CAD. Primary endpoints including death, myocardial infarction, hospitalization for unstable angina, or major procedural complication occurred in 3.3% of CTA patients and 3.0% of functional testing patients (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA patients received fewer catheterizations showing nonobstructive CAD (3.4% of versus 4.3%, P=0.02).

More CTA patients underwent catheterization within 90 days after randomization (12.2% vs 8.1%), however. Patients in the CTA group had higher exposures to radiation overall, but, per patient, their mean cumulative radiation dose was lower than that of the functional testing group (10.0 mSv vs. 11.3 mSv).

Interestingly, 6.2% of CTA patients versus 3.2% of functional testing patients underwent revascularization, but the study was not powered to assess invasive catheterization or revascularization rates on outcomes.

This study is interesting because results are generalizable to real-world settings; CTA did not improve outcomes compared to functional testing in patients undergoing testing for CAD.

Bottom line: No improvement was seen in clinical outcomes for symptomatic patients undergoing evaluation for CAD with CTA compared with those receiving functional testing.

Citation: Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300.

Clinical question: Does CT angiography (CTA) improve clinical outcomes in patients with new-onset stable chest pain more than functional testing?

Background: Chest pain is a common clinical problem, and multiple noninvasive tests are available to detect coronary artery disease (CAD). CT angiography is more accurate than noninvasive testing and may decrease unnecessary invasive testing and improve outcomes in patients with new-onset stable chest pain.

Study design: Pragmatic, comparative-effectiveness design.

Setting: One hundred ninety-three North American sites.

Synopsis: Ten thousand three symptomatic outpatients, mean age 60 years, with at least one cardiovascular risk factor, were randomized to CTA or functional testing to detect CAD. Primary endpoints including death, myocardial infarction, hospitalization for unstable angina, or major procedural complication occurred in 3.3% of CTA patients and 3.0% of functional testing patients (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA patients received fewer catheterizations showing nonobstructive CAD (3.4% of versus 4.3%, P=0.02).

More CTA patients underwent catheterization within 90 days after randomization (12.2% vs 8.1%), however. Patients in the CTA group had higher exposures to radiation overall, but, per patient, their mean cumulative radiation dose was lower than that of the functional testing group (10.0 mSv vs. 11.3 mSv).

Interestingly, 6.2% of CTA patients versus 3.2% of functional testing patients underwent revascularization, but the study was not powered to assess invasive catheterization or revascularization rates on outcomes.

This study is interesting because results are generalizable to real-world settings; CTA did not improve outcomes compared to functional testing in patients undergoing testing for CAD.

Bottom line: No improvement was seen in clinical outcomes for symptomatic patients undergoing evaluation for CAD with CTA compared with those receiving functional testing.

Citation: Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300.

Clinical question: Does CT angiography (CTA) improve clinical outcomes in patients with new-onset stable chest pain more than functional testing?

Background: Chest pain is a common clinical problem, and multiple noninvasive tests are available to detect coronary artery disease (CAD). CT angiography is more accurate than noninvasive testing and may decrease unnecessary invasive testing and improve outcomes in patients with new-onset stable chest pain.

Study design: Pragmatic, comparative-effectiveness design.

Setting: One hundred ninety-three North American sites.

Synopsis: Ten thousand three symptomatic outpatients, mean age 60 years, with at least one cardiovascular risk factor, were randomized to CTA or functional testing to detect CAD. Primary endpoints including death, myocardial infarction, hospitalization for unstable angina, or major procedural complication occurred in 3.3% of CTA patients and 3.0% of functional testing patients (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA patients received fewer catheterizations showing nonobstructive CAD (3.4% of versus 4.3%, P=0.02).

More CTA patients underwent catheterization within 90 days after randomization (12.2% vs 8.1%), however. Patients in the CTA group had higher exposures to radiation overall, but, per patient, their mean cumulative radiation dose was lower than that of the functional testing group (10.0 mSv vs. 11.3 mSv).

Interestingly, 6.2% of CTA patients versus 3.2% of functional testing patients underwent revascularization, but the study was not powered to assess invasive catheterization or revascularization rates on outcomes.

This study is interesting because results are generalizable to real-world settings; CTA did not improve outcomes compared to functional testing in patients undergoing testing for CAD.

Bottom line: No improvement was seen in clinical outcomes for symptomatic patients undergoing evaluation for CAD with CTA compared with those receiving functional testing.

Citation: Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300.

Background: Recent trials (ARISE, ProCESS) showed EGDT provided no mortality benefit over usual care. Questions remain about the effectiveness of intensive monitoring protocols, as well as the evolution of what constitutes usual care. The ProMISe trial seeks to test the hypothesis that EGDT impacts mortality in a cost-effective way.

Study design: Pragmatic, open, multicenter, parallel group RCT.

Setting: English National Health Service hospitals that did not routinely use EGDT that included continuous ScvO2 monitoring.

Synopsis: The authors enrolled 1,260 adult patients with early severe sepsis or septic shock; they randomized patients to either usual care or EGDT for six hours. Data was collected prospectively on the EGDT group and retrospectively on the usual care group.

By intention-to-treat analysis, all-cause mortality at 90 days was not significantly different (unadjusted RR 1.01, 95% CI, 0.85-1.20; adjusted OR 0.95, 95% CI, 0.74-1.24, P=0.73). EGDT patients received more intensive therapy, their quality of life scores were similar, and their average costs were higher, though not statistically significant. The probability that EGDT was cost effective was calculated to be below 20%.

Usual care patients had lower-than-expected mortality (29% vs. 40%), limiting the treatment effect of EGDT and limiting extrapolation to groups with higher mortality. Comparison to older studies is limited by the evolution in usual care for sepsis, with earlier recognition and antibiotic administration and greater use of vasoactive drugs. This study adds significant information about quality of life and cost to the discussion about EGDT.

Bottom line: The ProMISe study completes a powerful trio of papers suggesting that EGDT might be an expensive option that offers no clinical benefit over usual care.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Background: Recent trials (ARISE, ProCESS) showed EGDT provided no mortality benefit over usual care. Questions remain about the effectiveness of intensive monitoring protocols, as well as the evolution of what constitutes usual care. The ProMISe trial seeks to test the hypothesis that EGDT impacts mortality in a cost-effective way.

Study design: Pragmatic, open, multicenter, parallel group RCT.

Setting: English National Health Service hospitals that did not routinely use EGDT that included continuous ScvO2 monitoring.

Synopsis: The authors enrolled 1,260 adult patients with early severe sepsis or septic shock; they randomized patients to either usual care or EGDT for six hours. Data was collected prospectively on the EGDT group and retrospectively on the usual care group.

By intention-to-treat analysis, all-cause mortality at 90 days was not significantly different (unadjusted RR 1.01, 95% CI, 0.85-1.20; adjusted OR 0.95, 95% CI, 0.74-1.24, P=0.73). EGDT patients received more intensive therapy, their quality of life scores were similar, and their average costs were higher, though not statistically significant. The probability that EGDT was cost effective was calculated to be below 20%.

Usual care patients had lower-than-expected mortality (29% vs. 40%), limiting the treatment effect of EGDT and limiting extrapolation to groups with higher mortality. Comparison to older studies is limited by the evolution in usual care for sepsis, with earlier recognition and antibiotic administration and greater use of vasoactive drugs. This study adds significant information about quality of life and cost to the discussion about EGDT.

Bottom line: The ProMISe study completes a powerful trio of papers suggesting that EGDT might be an expensive option that offers no clinical benefit over usual care.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Background: Recent trials (ARISE, ProCESS) showed EGDT provided no mortality benefit over usual care. Questions remain about the effectiveness of intensive monitoring protocols, as well as the evolution of what constitutes usual care. The ProMISe trial seeks to test the hypothesis that EGDT impacts mortality in a cost-effective way.

Study design: Pragmatic, open, multicenter, parallel group RCT.

Setting: English National Health Service hospitals that did not routinely use EGDT that included continuous ScvO2 monitoring.

Synopsis: The authors enrolled 1,260 adult patients with early severe sepsis or septic shock; they randomized patients to either usual care or EGDT for six hours. Data was collected prospectively on the EGDT group and retrospectively on the usual care group.

By intention-to-treat analysis, all-cause mortality at 90 days was not significantly different (unadjusted RR 1.01, 95% CI, 0.85-1.20; adjusted OR 0.95, 95% CI, 0.74-1.24, P=0.73). EGDT patients received more intensive therapy, their quality of life scores were similar, and their average costs were higher, though not statistically significant. The probability that EGDT was cost effective was calculated to be below 20%.

Usual care patients had lower-than-expected mortality (29% vs. 40%), limiting the treatment effect of EGDT and limiting extrapolation to groups with higher mortality. Comparison to older studies is limited by the evolution in usual care for sepsis, with earlier recognition and antibiotic administration and greater use of vasoactive drugs. This study adds significant information about quality of life and cost to the discussion about EGDT.

Bottom line: The ProMISe study completes a powerful trio of papers suggesting that EGDT might be an expensive option that offers no clinical benefit over usual care.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Is there increased risk of bleeding or cardiovascular events when using NSAIDs while on antithrombotic therapy for secondary cardiovascular prevention?

Background: NSAIDs are among the most commonly used medications, despite the fact that individual NSAIDs have been associated with increased cardiovascular risk, and despite guidelines recommending against the use of NSAIDs in patients with cardiovascular disease. The risk of using NSAIDs with antithrombotic medications after first MI has not yet been examined.

Study design: Retrospective registry study.

Setting: Patients registered in official medical, pharmacy, and civil databases in Denmark, with unique individual identifier numbers allowing for database cross-reference.

Synopsis: The authors enrolled 61,971 patients of a possible 88,662 who were 30 years or older and admitted for a first-time MI starting 30 days following discharge, and tracked them for endpoint events and prescriptions. NSAID prescriptions were identified for 20,931 patients. Patients were placed in cohorts by their specific antithrombotic regimen (monotherapy, or combination therapy with aspirin, clopidogrel, or vitamin K antagonist) and specific NSAID use, accounting for changes in prescription combinations for a given individual.

Antithrombotic use between the NSAID and non-NSAID groups was equal. NSAID use, regardless of duration, was associated with increased risk of admission or death from bleeding (HR 2.02, 95% CI 1.81-2.26). NSAID use was also associated with increased cardiovascular endpoints (HR 1.40, 95% CI 1.30-1.49), including with the most common antithrombotic regimens.

This study is limited by its observational design, lack of more detailed database information, and use of prescription data. Differences in mortality were not separately presented. This study implies that even short exposures to NSAIDs while on antithrombotic therapy may be problematic.

Bottom line: NSAID use is associated with significant bleeding and cardiovascular events in patients who are on antithrombotic medications following their first MI.

Citation: Schjerning Olsen AM, Gislason GH, McGettigan P, et al. Association of NSAID use with risk of bleeding and cardiovascular events in patients receiving antithrombotic therapy after myocardial infarction. JAMA. 2015;313(8):805-814.

Clinical question: Is there increased risk of bleeding or cardiovascular events when using NSAIDs while on antithrombotic therapy for secondary cardiovascular prevention?

Background: NSAIDs are among the most commonly used medications, despite the fact that individual NSAIDs have been associated with increased cardiovascular risk, and despite guidelines recommending against the use of NSAIDs in patients with cardiovascular disease. The risk of using NSAIDs with antithrombotic medications after first MI has not yet been examined.

Study design: Retrospective registry study.

Setting: Patients registered in official medical, pharmacy, and civil databases in Denmark, with unique individual identifier numbers allowing for database cross-reference.

Synopsis: The authors enrolled 61,971 patients of a possible 88,662 who were 30 years or older and admitted for a first-time MI starting 30 days following discharge, and tracked them for endpoint events and prescriptions. NSAID prescriptions were identified for 20,931 patients. Patients were placed in cohorts by their specific antithrombotic regimen (monotherapy, or combination therapy with aspirin, clopidogrel, or vitamin K antagonist) and specific NSAID use, accounting for changes in prescription combinations for a given individual.

Antithrombotic use between the NSAID and non-NSAID groups was equal. NSAID use, regardless of duration, was associated with increased risk of admission or death from bleeding (HR 2.02, 95% CI 1.81-2.26). NSAID use was also associated with increased cardiovascular endpoints (HR 1.40, 95% CI 1.30-1.49), including with the most common antithrombotic regimens.

This study is limited by its observational design, lack of more detailed database information, and use of prescription data. Differences in mortality were not separately presented. This study implies that even short exposures to NSAIDs while on antithrombotic therapy may be problematic.

Bottom line: NSAID use is associated with significant bleeding and cardiovascular events in patients who are on antithrombotic medications following their first MI.

Citation: Schjerning Olsen AM, Gislason GH, McGettigan P, et al. Association of NSAID use with risk of bleeding and cardiovascular events in patients receiving antithrombotic therapy after myocardial infarction. JAMA. 2015;313(8):805-814.

Clinical question: Is there increased risk of bleeding or cardiovascular events when using NSAIDs while on antithrombotic therapy for secondary cardiovascular prevention?

Background: NSAIDs are among the most commonly used medications, despite the fact that individual NSAIDs have been associated with increased cardiovascular risk, and despite guidelines recommending against the use of NSAIDs in patients with cardiovascular disease. The risk of using NSAIDs with antithrombotic medications after first MI has not yet been examined.

Study design: Retrospective registry study.

Setting: Patients registered in official medical, pharmacy, and civil databases in Denmark, with unique individual identifier numbers allowing for database cross-reference.

Synopsis: The authors enrolled 61,971 patients of a possible 88,662 who were 30 years or older and admitted for a first-time MI starting 30 days following discharge, and tracked them for endpoint events and prescriptions. NSAID prescriptions were identified for 20,931 patients. Patients were placed in cohorts by their specific antithrombotic regimen (monotherapy, or combination therapy with aspirin, clopidogrel, or vitamin K antagonist) and specific NSAID use, accounting for changes in prescription combinations for a given individual.

Antithrombotic use between the NSAID and non-NSAID groups was equal. NSAID use, regardless of duration, was associated with increased risk of admission or death from bleeding (HR 2.02, 95% CI 1.81-2.26). NSAID use was also associated with increased cardiovascular endpoints (HR 1.40, 95% CI 1.30-1.49), including with the most common antithrombotic regimens.

This study is limited by its observational design, lack of more detailed database information, and use of prescription data. Differences in mortality were not separately presented. This study implies that even short exposures to NSAIDs while on antithrombotic therapy may be problematic.

Bottom line: NSAID use is associated with significant bleeding and cardiovascular events in patients who are on antithrombotic medications following their first MI.

Citation: Schjerning Olsen AM, Gislason GH, McGettigan P, et al. Association of NSAID use with risk of bleeding and cardiovascular events in patients receiving antithrombotic therapy after myocardial infarction. JAMA. 2015;313(8):805-814.

An examination for the new Certificate of Added Qualifications (CAQ) in hospital medicine for physician assistants (PAs) will be offered for the second time on August 24. It is one of seven CAQ specializations developed by the National Commission on Certification of Physician Assistants (NCCPA).

Fifty-three PAs earned the credential in 2014, while NCCPA estimates that 3,000 of the country’s 102,000 certified PAs are now working in hospitals—making it one of the profession’s fastest growing specialties.

Deadline to apply for the 2015 exam is Aug. 19. For more information, visit www.nccpa.net.

An examination for the new Certificate of Added Qualifications (CAQ) in hospital medicine for physician assistants (PAs) will be offered for the second time on August 24. It is one of seven CAQ specializations developed by the National Commission on Certification of Physician Assistants (NCCPA).

Fifty-three PAs earned the credential in 2014, while NCCPA estimates that 3,000 of the country’s 102,000 certified PAs are now working in hospitals—making it one of the profession’s fastest growing specialties.

Deadline to apply for the 2015 exam is Aug. 19. For more information, visit www.nccpa.net.

An examination for the new Certificate of Added Qualifications (CAQ) in hospital medicine for physician assistants (PAs) will be offered for the second time on August 24. It is one of seven CAQ specializations developed by the National Commission on Certification of Physician Assistants (NCCPA).

Fifty-three PAs earned the credential in 2014, while NCCPA estimates that 3,000 of the country’s 102,000 certified PAs are now working in hospitals—making it one of the profession’s fastest growing specialties.

Deadline to apply for the 2015 exam is Aug. 19. For more information, visit www.nccpa.net.

“Are you comfortable talking to him about all this stuff?” my attending asked me casually.

“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.

STOP!

Hold on. What did I just agree to do?

More than a decade later, I still feel the nervous tension in my stomach as I think about that day.

It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.

A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).

I knocked on the door and reached for the doorknob.

As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.

I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.

He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.

Post-Meeting Blues

I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.

As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:

I should have asked him if he had family.

I should have asked him who his gastroenterologist was.

I should have called his gastroenterologist.

I should have put a hand on his shoulder and told him we would figure this out together.

I should have told him he wasn’t alone.

I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.

I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.

I’m So Glad To See You

Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.

Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.

I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.

Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.

To me, that day was the day I joined the medical profession.

I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.

Lessons Learned

To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.

There are three lessons that I’ll never forget in my practice of hospital medicine:

Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.

If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.

Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.

Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.

Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.

“Are you comfortable talking to him about all this stuff?” my attending asked me casually.

“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.

STOP!

Hold on. What did I just agree to do?

More than a decade later, I still feel the nervous tension in my stomach as I think about that day.

It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.

A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).

I knocked on the door and reached for the doorknob.

As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.

I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.

He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.

Post-Meeting Blues

I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.

As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:

I should have asked him if he had family.

I should have asked him who his gastroenterologist was.

I should have called his gastroenterologist.

I should have put a hand on his shoulder and told him we would figure this out together.

I should have told him he wasn’t alone.

I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.

I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.

I’m So Glad To See You

Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.

Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.

I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.

Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.

To me, that day was the day I joined the medical profession.

I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.

Lessons Learned

To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.

There are three lessons that I’ll never forget in my practice of hospital medicine:

Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.

If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.

Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.

Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.

Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.

“Are you comfortable talking to him about all this stuff?” my attending asked me casually.

“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.

STOP!

Hold on. What did I just agree to do?

More than a decade later, I still feel the nervous tension in my stomach as I think about that day.

It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.

A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).

I knocked on the door and reached for the doorknob.

As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.

I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.

He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.

Post-Meeting Blues

I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.

As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:

I should have asked him if he had family.

I should have asked him who his gastroenterologist was.

I should have called his gastroenterologist.

I should have put a hand on his shoulder and told him we would figure this out together.

I should have told him he wasn’t alone.

I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.

I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.

I’m So Glad To See You

Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.

Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.

I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.

Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.

To me, that day was the day I joined the medical profession.

I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.

Lessons Learned

To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.

There are three lessons that I’ll never forget in my practice of hospital medicine:

Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.

If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.

Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.

Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.

Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.

A trickle of anecdotes has become a flood of cautionary tales.

There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”¹

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.²

In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.³ A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.² If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

A Culture of “More”

What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:

• Physician training and culture;
• The fee-for-service payment structure;
• Aggressive marketing by developers of tests, drugs, and procedures;
• Defensive medicine;
• A cultural preference for technological solutions; and
• A lack of transparency on the true costs of care.

The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”

A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.

At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.

“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”

Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.

“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.

Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.

“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.

High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.

The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.

I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco

“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.

Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”

As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.

“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”

It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”

Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.

Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.

Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?

More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver

After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.

Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.

Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.

“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”

In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.⁴

Signs of Progress

Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.

Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.⁵

“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.

The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.

“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.

In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.⁶ By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.

Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care

To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.⁷

First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.

Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.

Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.

“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”

Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.

Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.

“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”

Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.

“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”

Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
2. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
3. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
4. Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
5. Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
6. Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
7. Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.

A trickle of anecdotes has become a flood of cautionary tales.

There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”¹

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.²

In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.³ A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.² If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

A Culture of “More”

What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:

• Physician training and culture;
• The fee-for-service payment structure;
• Aggressive marketing by developers of tests, drugs, and procedures;
• Defensive medicine;
• A cultural preference for technological solutions; and
• A lack of transparency on the true costs of care.

The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”

A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.

At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.

“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”

Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.

“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.

Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.

“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.

High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.

The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.

I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco

“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.

Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”

As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.

“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”

It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”

Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.

Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.

Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?

More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver

After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.

Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.

Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.

“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”

In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.⁴

Signs of Progress

Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.

Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.⁵

“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.

The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.

“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.

In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.⁶ By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.

Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care

To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.⁷

First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.

Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.

Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.

“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”

Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.

Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.

“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”

Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.

“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”

Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
2. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
3. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
4. Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
5. Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
6. Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
7. Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.

A trickle of anecdotes has become a flood of cautionary tales.

There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”¹

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.²

In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.³ A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.² If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

A Culture of “More”

What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:

• Physician training and culture;
• The fee-for-service payment structure;
• Aggressive marketing by developers of tests, drugs, and procedures;
• Defensive medicine;
• A cultural preference for technological solutions; and
• A lack of transparency on the true costs of care.

The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”

A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.

At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.

“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”

Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.

“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.

Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.

“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.

High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.

The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.

I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco

“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.

Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”

As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.

“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”

It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”

Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.

Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.

Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?

More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver

After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.

Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.

Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.

“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”

In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.⁴

Signs of Progress

Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.

Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.⁵

“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.

The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.

“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.

In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.⁶ By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.

Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care

To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.⁷

First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.

Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.

Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.

“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”

Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.

Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.

“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”

Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.

“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”

Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
2. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
3. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
4. Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
5. Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
6. Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
7. Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.

Everyday, throughout the day, hospitalists and other healthcare workers are inundated with alerts and warnings and notifications from medical and communication devices. The sheer number of alarms can be extremely overwhelming.

“In any given unit, there may be hundreds of alarms per patient, per day,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill. “That amounts to tens of thousands of alarms each day.”

And, although the intent of these alarms may be good, studies show that 80% to 99% of alarms generated by such medical devices as ventilators, blood pressure monitors, and electrocardiograms are false and/or don’t actually require any clinical intervention.^1-4 What’s even more alarming is that clinicians become desensitized—even immune—to the sounds, experiencing what has been called “alarm fatigue.” In response to the constant barrage of noise, clinicians may turn alarms down or off, or adjust alarm settings outside limits that are safe and appropriate for the patient.⁵

The extent to which alarm fatigue has affected patients is unknown. From 2009 to 2012, The Joint Commission reported 98 alarm-related events. Of these, 80 resulted in death, 13 in permanent loss of function, and five in unexpected additional care or extended stay. Because sentinel event reporting to The Joint Commission is voluntary, Dr. Wyatt estimates that the organization is notified of less than 10% of such events.

Maria Cvach, DNP, RN, MSN, CCRN, DNP, assistant director of nursing for clinical standards at The Johns Hopkins Hospital in Baltimore, Md., says that from 2005 to 2008, there were 566 alarm-related deaths reported to the U.S. Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database. “Most experts agree that this is grossly underreported,” says Cvach, who has led alarm system improvement efforts at Hopkins since 2006.

In addition to being a patient safety issue, alarm fatigue has other consequences, Cvach says. Patients and families lose trust in staff when alarms go unanswered. Excessive noise can result in patient and staff harm. Research demonstrates that noise can negatively affect patients’ cardiovascular and immune systems and can increase length of hospital stays. Staff may develop stress symptoms and headaches. In addition, hospitals could face litigation from missed alarms and patient events.

From Bad to Worse

Experts agree that alarm fatigue is getting worse system-wide. ECRI Institute, a nonprofit organization that uses applied scientific research in healthcare to establish best practices for improving patient care, has listed alarm hazards as the number one health technology device hazard for the past three years. This persistent danger has made the top 10 since the list’s inception.⁶

Cvach says alarm fatigue is fairly easy to recognize.

“If you’re on a unit and hear alarms but do not see anyone addressing them, you are probably witnessing alarm fatigue,” she says. “If you ask staff what is alarming and they indicate that they didn’t notice an alarm ringing, it is likely alarm fatigue. Staff have indicated that sometimes alarms are like ‘white noise.’ [Alarms] go unnoticed because they are considered part of the environment and [staff] are accustomed to them.”

Jairy C. Hunter III, MD, MBA, SFHM, hospitalist and associate CMO for care transitions at Medical University of South Carolina (MUSC) in Charleston, believes alarm fatigue is a problem at every hospital, including his own. In addition to being bombarded with medical device alarms, he is constantly receiving notifications via cell phone, pager, and computers.

“Personally, I feel that I suffer from it [alarm fatigue],” says Dr. Hunter, a member of Team Hospitalist. “When I’m not at work and check my phones, I may realize that I missed answering a few notifications.”

He says that sometimes too much information “may be a bad thing, because we aren’t able to discern what is important and what isn’t. Studies have shown that, in general, people are not good at multi-tasking.”⁷

Staff have indicated that sometimes alarms are like ‘white noise.’ [Alarms] go unnoticed because they are considered part of the environment and [staff] are accustomed to them.”–Maria Cvach, DNP, RN, MSN, CCRN, DNP

Reduction Efforts

Dr. Wyatt believes the corrective actions organizations have implemented to reduce alarm fatigue are not optimal, because the problem is worsening. In addition, the number of patients who are connected to alarm-based devices will continue to increase.

He maintains that hospitalists are uniquely positioned to “team up” with housestaff and tackle this issue.

“Unlike other physicians, [hospitalists] are in the hospital around the clock,” he says.

Dr. Wyatt suggests a good starting point is determining the baseline number of device alarms per day. Then answer these questions:

• How many required clinical intervention?
• How many resulted in harm or death?
• What are the organization’s current monitor alarm default parameters?
• How can we adjust alarms to indicate actionable alarms?

Another tip: Work with engineers and equipment manufacturers to customize alarms and notifications, so staff can readily recognize those that need immediate attention.

Cvach says that unnecessary patient monitoring results in excessive nuisance alarms. Patients should only be monitored when clinically necessary. To determine necessity, refer to the American Heart Association’s Practice Standards for Electrocardiographic Monitoring in Hospital Settings.⁸

“Alarms should be individualized for patients to make them most useful,” she explains. “Defaults should be customized based on the patient population.”

Cvach also recommends momentarily pausing alarms when assisting patients with turning, suctioning, bathing, and so forth, and changing electrodes regularly.

From a personal perspective, Dr. Hunter suggests that hospitalists turn off as many nonessential notifications as possible and have separate devices for work and personal usage. Reset the tolerance for only certain important types of messages.

“I indicate specific parameters for a nurse or another provider to call me in certain circumstances,” Dr. Hunter says. “That grabs my attention more than a text or e-mail.”

Telling Patients

Vladimir N. Cadet, MPH, an associate with ECRI Institute’s Applied Solutions Group in Plymouth Meeting, Pa., says hospitalists should communicate to patients and their family members, many of whom also suffer from alarm fatigue, the importance of allowing health practitioners to address alarms to minimize the potential for delayed responses or missed alarms.

Patients should be told to notify staff if a medical device alarm goes unanswered, Cvach adds. To facilitate adequate sleep, patients can request earplugs or put on restful music.

Karen Appold is freelance writer in Pennsylvania.

References

1. Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Crit Care Med. 1994;22(6):981-985.
2. Tsien CL, Fackler JC. Poor prognosis of existing monitors in the intensive care unit. Crit Care Med. 1997;25(4):614-619.
3. Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C, Boniface B. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Med. 1999;25(12):1360-1366.
4. Atzema C, Schull MJ, Borgundvaag B, Slaughter GRD, Lee CK. Alarmed: adverse events in low-risk patients with chest pain receiving electrocardiographic monitoring in the emergency department: a pilot study. Am J Emerg Med. 2006;24(1):62-67.
5. Keller JP, Diefes R, Graham K, Meyers M, Pelczarski K. Association for the Advancement of Medical Instrumentation. Why clinical alarms are a “top ten” hazard: how you can help reduce the risk. Horizons. Spring 2011. Available at: http://www.aami.org/htsi/alarms/pdfs/Alarms%20Horizons_Secure_Watermarked.pdf. Accessed March 8, 2015.
6. ECRI Institute. Top 10 health technology hazards for 2015. Available at: https://www.ecri.org/press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology-Hazards-for-2015.aspx. Accessed March 8, 2015
7. Weigl M1, Müller A, Sevdalis N, Angerer P. Relationships of multitasking, physicians’ strain, and performance: an observational study in ward physicians. J Patient Saf. 2013 Mar;9(1):18-23. doi: 10.1097/PTS.0b013e31826b7b87.
8. Drew B, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. 2004;110:2721-2746.

Everyday, throughout the day, hospitalists and other healthcare workers are inundated with alerts and warnings and notifications from medical and communication devices. The sheer number of alarms can be extremely overwhelming.

“In any given unit, there may be hundreds of alarms per patient, per day,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill. “That amounts to tens of thousands of alarms each day.”

And, although the intent of these alarms may be good, studies show that 80% to 99% of alarms generated by such medical devices as ventilators, blood pressure monitors, and electrocardiograms are false and/or don’t actually require any clinical intervention.^1-4 What’s even more alarming is that clinicians become desensitized—even immune—to the sounds, experiencing what has been called “alarm fatigue.” In response to the constant barrage of noise, clinicians may turn alarms down or off, or adjust alarm settings outside limits that are safe and appropriate for the patient.⁵

The extent to which alarm fatigue has affected patients is unknown. From 2009 to 2012, The Joint Commission reported 98 alarm-related events. Of these, 80 resulted in death, 13 in permanent loss of function, and five in unexpected additional care or extended stay. Because sentinel event reporting to The Joint Commission is voluntary, Dr. Wyatt estimates that the organization is notified of less than 10% of such events.

Maria Cvach, DNP, RN, MSN, CCRN, DNP, assistant director of nursing for clinical standards at The Johns Hopkins Hospital in Baltimore, Md., says that from 2005 to 2008, there were 566 alarm-related deaths reported to the U.S. Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database. “Most experts agree that this is grossly underreported,” says Cvach, who has led alarm system improvement efforts at Hopkins since 2006.

In addition to being a patient safety issue, alarm fatigue has other consequences, Cvach says. Patients and families lose trust in staff when alarms go unanswered. Excessive noise can result in patient and staff harm. Research demonstrates that noise can negatively affect patients’ cardiovascular and immune systems and can increase length of hospital stays. Staff may develop stress symptoms and headaches. In addition, hospitals could face litigation from missed alarms and patient events.

From Bad to Worse

Experts agree that alarm fatigue is getting worse system-wide. ECRI Institute, a nonprofit organization that uses applied scientific research in healthcare to establish best practices for improving patient care, has listed alarm hazards as the number one health technology device hazard for the past three years. This persistent danger has made the top 10 since the list’s inception.⁶

Cvach says alarm fatigue is fairly easy to recognize.

“If you’re on a unit and hear alarms but do not see anyone addressing them, you are probably witnessing alarm fatigue,” she says. “If you ask staff what is alarming and they indicate that they didn’t notice an alarm ringing, it is likely alarm fatigue. Staff have indicated that sometimes alarms are like ‘white noise.’ [Alarms] go unnoticed because they are considered part of the environment and [staff] are accustomed to them.”

Jairy C. Hunter III, MD, MBA, SFHM, hospitalist and associate CMO for care transitions at Medical University of South Carolina (MUSC) in Charleston, believes alarm fatigue is a problem at every hospital, including his own. In addition to being bombarded with medical device alarms, he is constantly receiving notifications via cell phone, pager, and computers.

“Personally, I feel that I suffer from it [alarm fatigue],” says Dr. Hunter, a member of Team Hospitalist. “When I’m not at work and check my phones, I may realize that I missed answering a few notifications.”

He says that sometimes too much information “may be a bad thing, because we aren’t able to discern what is important and what isn’t. Studies have shown that, in general, people are not good at multi-tasking.”⁷

Staff have indicated that sometimes alarms are like ‘white noise.’ [Alarms] go unnoticed because they are considered part of the environment and [staff] are accustomed to them.”–Maria Cvach, DNP, RN, MSN, CCRN, DNP

Reduction Efforts

Dr. Wyatt believes the corrective actions organizations have implemented to reduce alarm fatigue are not optimal, because the problem is worsening. In addition, the number of patients who are connected to alarm-based devices will continue to increase.

He maintains that hospitalists are uniquely positioned to “team up” with housestaff and tackle this issue.

“Unlike other physicians, [hospitalists] are in the hospital around the clock,” he says.

Dr. Wyatt suggests a good starting point is determining the baseline number of device alarms per day. Then answer these questions:

• How many required clinical intervention?
• How many resulted in harm or death?
• What are the organization’s current monitor alarm default parameters?
• How can we adjust alarms to indicate actionable alarms?

Another tip: Work with engineers and equipment manufacturers to customize alarms and notifications, so staff can readily recognize those that need immediate attention.

Cvach says that unnecessary patient monitoring results in excessive nuisance alarms. Patients should only be monitored when clinically necessary. To determine necessity, refer to the American Heart Association’s Practice Standards for Electrocardiographic Monitoring in Hospital Settings.⁸

“Alarms should be individualized for patients to make them most useful,” she explains. “Defaults should be customized based on the patient population.”

Cvach also recommends momentarily pausing alarms when assisting patients with turning, suctioning, bathing, and so forth, and changing electrodes regularly.

From a personal perspective, Dr. Hunter suggests that hospitalists turn off as many nonessential notifications as possible and have separate devices for work and personal usage. Reset the tolerance for only certain important types of messages.

“I indicate specific parameters for a nurse or another provider to call me in certain circumstances,” Dr. Hunter says. “That grabs my attention more than a text or e-mail.”

Telling Patients

Vladimir N. Cadet, MPH, an associate with ECRI Institute’s Applied Solutions Group in Plymouth Meeting, Pa., says hospitalists should communicate to patients and their family members, many of whom also suffer from alarm fatigue, the importance of allowing health practitioners to address alarms to minimize the potential for delayed responses or missed alarms.

Patients should be told to notify staff if a medical device alarm goes unanswered, Cvach adds. To facilitate adequate sleep, patients can request earplugs or put on restful music.

Karen Appold is freelance writer in Pennsylvania.

References

1. Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Crit Care Med. 1994;22(6):981-985.
2. Tsien CL, Fackler JC. Poor prognosis of existing monitors in the intensive care unit. Crit Care Med. 1997;25(4):614-619.
3. Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C, Boniface B. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Med. 1999;25(12):1360-1366.
4. Atzema C, Schull MJ, Borgundvaag B, Slaughter GRD, Lee CK. Alarmed: adverse events in low-risk patients with chest pain receiving electrocardiographic monitoring in the emergency department: a pilot study. Am J Emerg Med. 2006;24(1):62-67.
5. Keller JP, Diefes R, Graham K, Meyers M, Pelczarski K. Association for the Advancement of Medical Instrumentation. Why clinical alarms are a “top ten” hazard: how you can help reduce the risk. Horizons. Spring 2011. Available at: http://www.aami.org/htsi/alarms/pdfs/Alarms%20Horizons_Secure_Watermarked.pdf. Accessed March 8, 2015.
6. ECRI Institute. Top 10 health technology hazards for 2015. Available at: https://www.ecri.org/press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology-Hazards-for-2015.aspx. Accessed March 8, 2015
7. Weigl M1, Müller A, Sevdalis N, Angerer P. Relationships of multitasking, physicians’ strain, and performance: an observational study in ward physicians. J Patient Saf. 2013 Mar;9(1):18-23. doi: 10.1097/PTS.0b013e31826b7b87.
8. Drew B, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. 2004;110:2721-2746.

Everyday, throughout the day, hospitalists and other healthcare workers are inundated with alerts and warnings and notifications from medical and communication devices. The sheer number of alarms can be extremely overwhelming.

“In any given unit, there may be hundreds of alarms per patient, per day,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill. “That amounts to tens of thousands of alarms each day.”

And, although the intent of these alarms may be good, studies show that 80% to 99% of alarms generated by such medical devices as ventilators, blood pressure monitors, and electrocardiograms are false and/or don’t actually require any clinical intervention.^1-4 What’s even more alarming is that clinicians become desensitized—even immune—to the sounds, experiencing what has been called “alarm fatigue.” In response to the constant barrage of noise, clinicians may turn alarms down or off, or adjust alarm settings outside limits that are safe and appropriate for the patient.⁵

The extent to which alarm fatigue has affected patients is unknown. From 2009 to 2012, The Joint Commission reported 98 alarm-related events. Of these, 80 resulted in death, 13 in permanent loss of function, and five in unexpected additional care or extended stay. Because sentinel event reporting to The Joint Commission is voluntary, Dr. Wyatt estimates that the organization is notified of less than 10% of such events.

Maria Cvach, DNP, RN, MSN, CCRN, DNP, assistant director of nursing for clinical standards at The Johns Hopkins Hospital in Baltimore, Md., says that from 2005 to 2008, there were 566 alarm-related deaths reported to the U.S. Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database. “Most experts agree that this is grossly underreported,” says Cvach, who has led alarm system improvement efforts at Hopkins since 2006.

In addition to being a patient safety issue, alarm fatigue has other consequences, Cvach says. Patients and families lose trust in staff when alarms go unanswered. Excessive noise can result in patient and staff harm. Research demonstrates that noise can negatively affect patients’ cardiovascular and immune systems and can increase length of hospital stays. Staff may develop stress symptoms and headaches. In addition, hospitals could face litigation from missed alarms and patient events.

From Bad to Worse

Experts agree that alarm fatigue is getting worse system-wide. ECRI Institute, a nonprofit organization that uses applied scientific research in healthcare to establish best practices for improving patient care, has listed alarm hazards as the number one health technology device hazard for the past three years. This persistent danger has made the top 10 since the list’s inception.⁶

Cvach says alarm fatigue is fairly easy to recognize.

“If you’re on a unit and hear alarms but do not see anyone addressing them, you are probably witnessing alarm fatigue,” she says. “If you ask staff what is alarming and they indicate that they didn’t notice an alarm ringing, it is likely alarm fatigue. Staff have indicated that sometimes alarms are like ‘white noise.’ [Alarms] go unnoticed because they are considered part of the environment and [staff] are accustomed to them.”

Jairy C. Hunter III, MD, MBA, SFHM, hospitalist and associate CMO for care transitions at Medical University of South Carolina (MUSC) in Charleston, believes alarm fatigue is a problem at every hospital, including his own. In addition to being bombarded with medical device alarms, he is constantly receiving notifications via cell phone, pager, and computers.

“Personally, I feel that I suffer from it [alarm fatigue],” says Dr. Hunter, a member of Team Hospitalist. “When I’m not at work and check my phones, I may realize that I missed answering a few notifications.”

He says that sometimes too much information “may be a bad thing, because we aren’t able to discern what is important and what isn’t. Studies have shown that, in general, people are not good at multi-tasking.”⁷

Staff have indicated that sometimes alarms are like ‘white noise.’ [Alarms] go unnoticed because they are considered part of the environment and [staff] are accustomed to them.”–Maria Cvach, DNP, RN, MSN, CCRN, DNP

Reduction Efforts

Dr. Wyatt believes the corrective actions organizations have implemented to reduce alarm fatigue are not optimal, because the problem is worsening. In addition, the number of patients who are connected to alarm-based devices will continue to increase.

He maintains that hospitalists are uniquely positioned to “team up” with housestaff and tackle this issue.

“Unlike other physicians, [hospitalists] are in the hospital around the clock,” he says.

Dr. Wyatt suggests a good starting point is determining the baseline number of device alarms per day. Then answer these questions:

• How many required clinical intervention?
• How many resulted in harm or death?
• What are the organization’s current monitor alarm default parameters?
• How can we adjust alarms to indicate actionable alarms?

Another tip: Work with engineers and equipment manufacturers to customize alarms and notifications, so staff can readily recognize those that need immediate attention.

Cvach says that unnecessary patient monitoring results in excessive nuisance alarms. Patients should only be monitored when clinically necessary. To determine necessity, refer to the American Heart Association’s Practice Standards for Electrocardiographic Monitoring in Hospital Settings.⁸

“Alarms should be individualized for patients to make them most useful,” she explains. “Defaults should be customized based on the patient population.”

Cvach also recommends momentarily pausing alarms when assisting patients with turning, suctioning, bathing, and so forth, and changing electrodes regularly.

From a personal perspective, Dr. Hunter suggests that hospitalists turn off as many nonessential notifications as possible and have separate devices for work and personal usage. Reset the tolerance for only certain important types of messages.

“I indicate specific parameters for a nurse or another provider to call me in certain circumstances,” Dr. Hunter says. “That grabs my attention more than a text or e-mail.”

Telling Patients

Vladimir N. Cadet, MPH, an associate with ECRI Institute’s Applied Solutions Group in Plymouth Meeting, Pa., says hospitalists should communicate to patients and their family members, many of whom also suffer from alarm fatigue, the importance of allowing health practitioners to address alarms to minimize the potential for delayed responses or missed alarms.

Patients should be told to notify staff if a medical device alarm goes unanswered, Cvach adds. To facilitate adequate sleep, patients can request earplugs or put on restful music.

Karen Appold is freelance writer in Pennsylvania.

References

1. Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Crit Care Med. 1994;22(6):981-985.
2. Tsien CL, Fackler JC. Poor prognosis of existing monitors in the intensive care unit. Crit Care Med. 1997;25(4):614-619.
3. Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C, Boniface B. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Med. 1999;25(12):1360-1366.
4. Atzema C, Schull MJ, Borgundvaag B, Slaughter GRD, Lee CK. Alarmed: adverse events in low-risk patients with chest pain receiving electrocardiographic monitoring in the emergency department: a pilot study. Am J Emerg Med. 2006;24(1):62-67.
5. Keller JP, Diefes R, Graham K, Meyers M, Pelczarski K. Association for the Advancement of Medical Instrumentation. Why clinical alarms are a “top ten” hazard: how you can help reduce the risk. Horizons. Spring 2011. Available at: http://www.aami.org/htsi/alarms/pdfs/Alarms%20Horizons_Secure_Watermarked.pdf. Accessed March 8, 2015.
6. ECRI Institute. Top 10 health technology hazards for 2015. Available at: https://www.ecri.org/press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology-Hazards-for-2015.aspx. Accessed March 8, 2015
7. Weigl M1, Müller A, Sevdalis N, Angerer P. Relationships of multitasking, physicians’ strain, and performance: an observational study in ward physicians. J Patient Saf. 2013 Mar;9(1):18-23. doi: 10.1097/PTS.0b013e31826b7b87.
8. Drew B, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. 2004;110:2721-2746.

Clinical question: Can bedside ultrasound reliably diagnose pneumonia in children?

Background: Pneumonia is the most common cause of death in children worldwide, one of the most common causes of inpatient admission for children in the U.S., and carries estimated costs of about $1 billion per year. Its diagnosis can challenge clinicians and require radiographic and laboratory studies. Chest radiographs require specialized equipment, expertise to interpret, and ionizing radiation exposure. Radiographic findings can also lag behind the clinical picture. Ultrasound, a rapid, noninvasive, portable, and inexpensive imaging modality that can be taught quickly, is widely used to diagnose such pediatric conditions as appendicitis and abscess and may be useful in diagnosing pediatric pneumonia.

Study design: Meta-analysis.

Setting: Eight studies reviewed and synthesized (three ED, two regular inpatient, one PICU, two NICU).

Synopsis: Lung ultrasound was compared to chest radiograph, lab findings, and clinical findings for detection of pneumonia. In pooled analysis, lung ultrasound was 96% sensitive and 93% specific for the diagnosis of pneumonia with area under the receiver operating characteristic (ROC) curve of 0.98 (95% CI 0.96-1). Subgroup analysis showed that having physicians who have had experience with more than 100 ultrasounds or radiologists performing the ultrasounds increased the sensitivity to 97% and the specificity to 99%. Novice users could detect pneumonia with less reliability.

Bottom line: Lung ultrasound is a promising and potentially reliable modality for diagnosis of pneumonia. This may prove especially useful in resource-poor settings or in clinics without access to chest radiographs.

Citation: Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta analysis. Pediatrics. 2015;135(4):714-722.

Clinical question: Can bedside ultrasound reliably diagnose pneumonia in children?

Background: Pneumonia is the most common cause of death in children worldwide, one of the most common causes of inpatient admission for children in the U.S., and carries estimated costs of about $1 billion per year. Its diagnosis can challenge clinicians and require radiographic and laboratory studies. Chest radiographs require specialized equipment, expertise to interpret, and ionizing radiation exposure. Radiographic findings can also lag behind the clinical picture. Ultrasound, a rapid, noninvasive, portable, and inexpensive imaging modality that can be taught quickly, is widely used to diagnose such pediatric conditions as appendicitis and abscess and may be useful in diagnosing pediatric pneumonia.

Study design: Meta-analysis.

Setting: Eight studies reviewed and synthesized (three ED, two regular inpatient, one PICU, two NICU).

Synopsis: Lung ultrasound was compared to chest radiograph, lab findings, and clinical findings for detection of pneumonia. In pooled analysis, lung ultrasound was 96% sensitive and 93% specific for the diagnosis of pneumonia with area under the receiver operating characteristic (ROC) curve of 0.98 (95% CI 0.96-1). Subgroup analysis showed that having physicians who have had experience with more than 100 ultrasounds or radiologists performing the ultrasounds increased the sensitivity to 97% and the specificity to 99%. Novice users could detect pneumonia with less reliability.

Bottom line: Lung ultrasound is a promising and potentially reliable modality for diagnosis of pneumonia. This may prove especially useful in resource-poor settings or in clinics without access to chest radiographs.

Citation: Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta analysis. Pediatrics. 2015;135(4):714-722.

Clinical question: Can bedside ultrasound reliably diagnose pneumonia in children?

Background: Pneumonia is the most common cause of death in children worldwide, one of the most common causes of inpatient admission for children in the U.S., and carries estimated costs of about $1 billion per year. Its diagnosis can challenge clinicians and require radiographic and laboratory studies. Chest radiographs require specialized equipment, expertise to interpret, and ionizing radiation exposure. Radiographic findings can also lag behind the clinical picture. Ultrasound, a rapid, noninvasive, portable, and inexpensive imaging modality that can be taught quickly, is widely used to diagnose such pediatric conditions as appendicitis and abscess and may be useful in diagnosing pediatric pneumonia.

Study design: Meta-analysis.

Setting: Eight studies reviewed and synthesized (three ED, two regular inpatient, one PICU, two NICU).

Synopsis: Lung ultrasound was compared to chest radiograph, lab findings, and clinical findings for detection of pneumonia. In pooled analysis, lung ultrasound was 96% sensitive and 93% specific for the diagnosis of pneumonia with area under the receiver operating characteristic (ROC) curve of 0.98 (95% CI 0.96-1). Subgroup analysis showed that having physicians who have had experience with more than 100 ultrasounds or radiologists performing the ultrasounds increased the sensitivity to 97% and the specificity to 99%. Novice users could detect pneumonia with less reliability.

Bottom line: Lung ultrasound is a promising and potentially reliable modality for diagnosis of pneumonia. This may prove especially useful in resource-poor settings or in clinics without access to chest radiographs.

Citation: Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta analysis. Pediatrics. 2015;135(4):714-722.

There are all kinds of ways to show your support for the hospital medicine movement, including the following opportunities:

• Visit and share the new Future of Hospital Medicine website (www.futureofhospitalmedicine.org) with medical students, residents, and colleagues.
• Plan to attend a Future of Hospital Medicine event in your city:

  • Chicago: Rush University, Sept. 24
  • Los Angeles: UCLA, Oct. 22

• Apply for FHM or SFHM status today! Now’s the time to begin the application process for Fellow in Hospital Medicine or Senior Fellow. Visit www.hospitalmedicine.org/fellows for details.
• Recruit others to join the movement. Active members can receive dues credits and special recognition for recruiting others. For details, visit www.hospitalmedicine.org/membership.
• Get the gear! Visit www.hospitalmedicine.org for the latest in hospitalist apparel, including new hoodies, coffee tumblers, water bottles, and tablet cases.

There are all kinds of ways to show your support for the hospital medicine movement, including the following opportunities:

• Visit and share the new Future of Hospital Medicine website (www.futureofhospitalmedicine.org) with medical students, residents, and colleagues.
• Plan to attend a Future of Hospital Medicine event in your city:

  • Chicago: Rush University, Sept. 24
  • Los Angeles: UCLA, Oct. 22

• Apply for FHM or SFHM status today! Now’s the time to begin the application process for Fellow in Hospital Medicine or Senior Fellow. Visit www.hospitalmedicine.org/fellows for details.
• Recruit others to join the movement. Active members can receive dues credits and special recognition for recruiting others. For details, visit www.hospitalmedicine.org/membership.
• Get the gear! Visit www.hospitalmedicine.org for the latest in hospitalist apparel, including new hoodies, coffee tumblers, water bottles, and tablet cases.

There are all kinds of ways to show your support for the hospital medicine movement, including the following opportunities:

• Visit and share the new Future of Hospital Medicine website (www.futureofhospitalmedicine.org) with medical students, residents, and colleagues.
• Plan to attend a Future of Hospital Medicine event in your city:

  • Chicago: Rush University, Sept. 24
  • Los Angeles: UCLA, Oct. 22

• Apply for FHM or SFHM status today! Now’s the time to begin the application process for Fellow in Hospital Medicine or Senior Fellow. Visit www.hospitalmedicine.org/fellows for details.
• Recruit others to join the movement. Active members can receive dues credits and special recognition for recruiting others. For details, visit www.hospitalmedicine.org/membership.
• Get the gear! Visit www.hospitalmedicine.org for the latest in hospitalist apparel, including new hoodies, coffee tumblers, water bottles, and tablet cases.