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

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

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

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

METHODS

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

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

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

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

RESULTS

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

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

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

METHODS

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

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

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

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

RESULTS

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

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

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

METHODS

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

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

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

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

RESULTS

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

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

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

CONCLUSIONS

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

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

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

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

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

A pneumothorax is a collection of air in the space outside the lungs that is trapped within the thorax. This abnormality can occur spontaneously or as the result of trauma. Traumatic pneumothoraces include those resulting from medical interventions such as a transthoracic and transbronchial needle biopsy, central line placement, and positive‐pressure mechanical ventilation. This group is most accurately described as iatrogenic pneumothorax (IP).[1]

IP can be an expected complication of many routine thoracic procedures, but it can also occur accidentally during procedures near the lung or thoracic cavity. Some IPs may be asymptomatic and go undiagnosed, or their diagnosis may be delayed.[2] The majority of iatrogenic pneumothoraces will resolve without complications, and patients will not require medical attention. A small percentage can, however, expand and have the potential to develop into a tension pneumothorax causing severe respiratory distress and mediastinal shift.[3, 4]

The incidence of IP ranges from 0.11% with mechanical ventilation to 2.68% with thoracentesis, according to an analysis of 7.5 million uniform hospital discharge abstracts from 2000.⁵ A 2010 systematic review of 24 studies that included 6605 patients suggested a 6.0% incidence of pneumothorax following thoracentesis.[3] The highest risk of IP is seen with computed tomography (CT)‐guided lung biopsy, with 1 series of 1098 biopsies showing a 42% incidence; chest tube evacuation was required in 12% of these cases.[4] A Veterans Administration study of patient safety indicators from 2001 to 2004 found that risk‐adjusted rates of IP were increasing over time.[6] It is unclear whether this increase is due to increasing numbers of interventional procedures or to better rates of detection. IP poses a considerable cost to the medical system, with safety studies finding that patients with IP will stay in the hospital approximately 4 days longer and incur an additional $17,000 in charges.[7]

In addition to this financial burden, the lack of consistency in training and guidelines for management of pneumothorax is thought to add to chest tube‐related complications.[8] In 2001, the American College of Chest Physicians (ACCP) published guidelines for the management of spontaneous pneumothorax that do not specifically address IP.[9] In 2010, the British Thoracic Society (BTS) updated their guidelines and included a brief statement on IP that described a higher incidence for it than for spontaneous pneumothorax and noted its relative ease of management.[10] Despite the lack of specific guidelines dedicated to IPs, common clinical practice is to manage iatrogenic defects in a manner similar to that for spontaneous ones. However, studies have shown that the management of pneumothorax remains diverse and that the adherence to these published guidelines is suboptimal.[10, 11] The BTS guidelines favor needle aspiration as the first‐line treatment,[10] whereas the ACCP recommends drainage with catheters over aspiration.[9]

The possibility of this complication, along with the rising rate of invasive interventions being performed, has led to expanded surveillance criteria for IP. Surveillance imaging, clinical observation, or a combination of the 2 may be required, depending on the institution, the risk of the procedure, and the preference of the treating clinician. The algorithms presented here were designed in alignment with both major society guidelines and with the intention of simplifying the treatment regimen for the ease of adoption by hospitalists.

ETIOLOGY AND RISK FACTORS

The etiology and risk factors for IP are multiple, with the most common being interventional‐based procedures. In 535 Veterans Administration patients, the most common precursor procedures were transthoracic needle biopsy (24%), subclavian vein catheterization (22%), thoracentesis (20%), transbronchial biopsy (10%), pleural biopsy (8%), and positive pressure ventilation.[12] IP can also be a rare complication of pacemaker manipulations,[5] and less commonly, bronchoscopy.[13] Patient factors that increase the risk of pneumothorax in the setting of an intervention include age, chronic obstructive lung disease, primary lung cancer, malignant and parapneumonic pleural effusions, empyema, and chronic corticosteroid use.[4] As might be expected, patients with structural lung disease (eg, emphysema with bullae) and poor healing ability (eg, corticosteroid dependent), tend to have IPs more often and to require more complicated interventions for resolution.[14, 15] In some studies, operator experience seems to be inversely related to the rate of IP, and the use of ultrasound is correlated with lower rates of this complication.[1, 3]

PATIENT PRESENTATIONS AND DIAGNOSIS

Clinical signs and symptoms of a significant pneumothorax vary in severity but most often include dyspnea, tachypnea, chest pain, and pleurisy (see Box 1). Post procedure signs or symptoms require further evaluation with imaging, usually a plain chest radiograph. CT can be useful for further evaluation. Small anterior pneumothoraces may be difficult to detect without lateral radiographic imaging or computed tomogram. Ultrasound is being used more frequently at the bedside to make this diagnosis, and various studies of trauma patients have found that it has good sensitivity and specificity.[16, 17] These results have been validated by a recent meta‐analysis comparing ultrasound to chest radiographs for the detection of pneumothorax among trauma, critically ill, and postprocedural patients.[18] This study demonstrated superior sensitivity and similar specificity for ultrasound versus chest radiographs for detection of pneumothorax. More ominous signs, such as tachycardia or hypotension, can be indicative of tension pneumothorax, which requires emergent evacuation.

MANAGEMENT

Once the diagnosis of pneumothorax has been established, treatment options should be guided by defect size and clinical assessment following a defined treatment algorithm (Figure 1). As emphasized by the BTS and ACCP guidelines, we advocate considering the use of symptoms along with defect size to determine the best management course.

Figure 1

Placement of Catheter or Chest Tube Drainage

Most patients with a clinically significant pneumothorax will require evacuation of the air. Pneumothoraces larger than 20% or that produce symptoms warrant chest tube management and inpatient observation (Figure 1B). Traditionally, large tubes with 20 cm of water on continuous suction are used and have been studied the most widely. Several authors have shown that smaller tubes can effectively drain a pneumothorax.[26, 27, 28, 29] Small‐bore catheters (8F14F), which can be inserted percutaneously, have been shown to provide effective lung re‐expansion with minimal morbidity[8] and may be better tolerated by patients with uncomplicated pneumothoraces (Figure 2). Terzi and colleagues[30] have shown that smaller tubes cause less discomfort to patients at rest, with cough, and at the time of tube removal.

Figure 2

At most US institutions, catheters and chest tubes are connected to all‐purpose drainage systems. Although commercially available through a variety of manufacturers, they share similar design principles because they replicate the 3‐bottle system described in detail elsewhere in the literature.[31] We have limited our discussion to 3 pleural evacuation systems because it is our intention to familiarize hospitalists with the units that they are most likely to encounter. The first 2 systems have been studied and described by Baumann and colleagues[32] as being commonplace and reasonably reliable. These include the Oasis (Atrium Medical Corp., Hudson, NH) (Figure 3A) and the Pleur‐evac (Teleflex Inc., Limerick, PA). The third unit is the Thopaz digital thoracic drainage system (Medela Inc., McHenry, IL) (Figure 3B). The Thopaz is unique in its inclusion of a suction source and digital capability. Although it utilizes the same principles of all pleural evacuation devices, its setup and information output require that one be familiar with its digital format.

Figure 3

Assessing for Air Leak

If there is improvement or resolution of the pneumothorax after 24 hours, the presence of an air leak should be assessed; if no leak is present, the chest tube can be safely removed. In the context of chest tubes, the term air leak refers to residual air between the lung and the chest wall. It is possible to see resolution of a pneumothorax on chest radiographs and still have an air leak. This situation is created by a perfect balance between the pleural air evacuation by the catheter and the flow of air exiting from the lung puncture. This would result in reaccumulation of the pneumothorax if the chest tube is removed prematurely. It should also be kept in mind that chest radiographs may miss a small pneumothorax given their relatively low sensitivity.[18] Therefore, the absence of an air leak needs to be documented before the chest tube is discontinued. Depending on the type of drainage system (Atrium, Pleur‐evac, or Thopaz), this assessment can be done in several ways. All systems can be assessed for air leak by clamping the actual chest tube for 2 to 4 hours and then repeating the chest radiograph. Clamping a chest tube simulates the condition of not having a chest tube. Chest tubes should never be clamped without supervision and only with the knowledge of nursing personnel. The onset of chest pain or dyspnea in a patient with a clamped tube mandates immediate removal of the clamp and a return to suction. A repeat chest radiograph showing reaccumulation or expansion of the pneumothorax after clamping indicates that the air leak has not resolved and the chest tube must remain in place and returned to suction. Simpler and more time‐efficient methods of detecting air leaks are available with both cardiothoracic drainage systems.

For the Atrium and Pleur‐evac models, there is a graded panel through which one can visualize air leaks being funneled through water (Figure 4A). Having the patient cough several times or perform a Valsalva maneuver should release any air trapped within the chest into this chamber, where bubbles can be visualized as they travel through the water. The presence of bubbles indicates the presence of residual air in the chest, pointing to a possible leak. In contrast, the Thopaz system offers a graphical display of the air flowing into the system that can be reviewed over the 24‐hour period. When the graph line reaches a 0 flatline graph, no airflow is being detected and no air leakage is suspected (Figure 4B). If no air leaks are detected, the chest tube may be discontinued. Those patients with a failed air leak test should have their chest tubes continued under suction for another 24 hours, with the above tests then repeated. The same holds true for those patients with persistent pneumothorax at 24 hours.

Figure 4

Removal of chest tubes is a simple process that requires the tube to be pulled out of the patient without allowing air to enter the site where the tube was present and where it entered the thorax. Most interventionalists will discontinue the tubes that they have placed. Some small catheters have an internal string that has to be released so the catheter will straighten and pull out easily. Knowledge of the type of catheter or tube that was placed is critical before removal to prevent complications and patient discomfort. Standard chest tubes are straight, smooth plastic and pull out easily but require rapid occlusion of the larger puncture site in the chest wall with an occlusive dressing that often includes petroleum or water‐soluble gel. Some physicians will leave a suture tie when placing the chest tube so that it can be tied down to occlude the site instead of using a dressing.

PRACTICAL TIPS

Hospitalists caring for patients with chest tubes are often asked to troubleshoot at the bedside. Scenarios that may be encountered include nonfunctioning tubes, catheter migration, and tube discomfort. Ensuring patency of the tube entails visualizing the tube from the point of entry into the chest wall to the collection chamber and inspecting for kinks or debris clogging the tube. Smaller catheters can be easily kinked during patient positioning and can become clogged. Respiratory variation, which is the movement of the column of fluid in the collection chamber or in the tubing with inspiration and expiration, suggests that the chest tube is patent. This should be part of the daily examination in a patient with a chest tube, and it should also be the first step in assessing sudden dyspnea, hypoxia, pain, or hemodynamic instability. Clogged tubes should be referred to the interventionalists or other physicians who placed them. Chest tubes are typically sutured at the site of entry and securely bandaged to avoid migration but occasionally can be dislodged. This should prompt placement of another tube by an experienced operator. Last, chest tubes can be uncomfortable for patients who may require systemic analgesics. Additionally, tube positioning may ease some of the discomfort. Chest tubes are commonly placed along the midaxillary line and the posterior thorax, leading to discomfort in the recumbent position. Directing the tube anteriorly helps ease some of the discomfort. This can be done using all‐purpose sponges to build a barrier between the skin and the chest tube as it is directed anteriorly. Additional sponges are placed above the tube for extra protection. The gentle curve accomplished by padding the underside of the tube also keeps the tube patent by avoiding sharp kinks as the catheter exits the thorax.

FUTURE TRENDS

Future trends in the management of IP may include shorter duration of tube management (14 hours of suction with air leak evaluation and removal) and the use of even smaller catheters. Outpatient management of IP with small pigtail catheters or small‐caliber tubes in addition to 1‐way valves is also being investigated. The benefits of these practices may include greater patient comfort and lower cost. These approaches will need larger‐scale replication and careful patient selection before they become standard practice.[28, 36]

Ultrasound can be used to assess the presence and size of pneumothoraces that are difficult to visualize by standard chest radiographs. Several studies have established ultrasonography as an effective method of diagnosing pneumothorax and have shown it to have superior sensitivity compared with chest radiography.[1, 18] In the future, the use of ultrasound will likely be more widespread given its performance, portability, ease of use, and relatively low cost.

SUMMARY

IP is a known and costly complication of many medical procedures. The aforementioned algorithms help simplify the management of chest tubes for hospitalists caring for patients with this common complication. This stepwise approach may not only help curtail added expenses related to IPs by decreasing the length of inpatient stays but may also improve patient satisfaction.

A pneumothorax is a collection of air in the space outside the lungs that is trapped within the thorax. This abnormality can occur spontaneously or as the result of trauma. Traumatic pneumothoraces include those resulting from medical interventions such as a transthoracic and transbronchial needle biopsy, central line placement, and positive‐pressure mechanical ventilation. This group is most accurately described as iatrogenic pneumothorax (IP).[1]

IP can be an expected complication of many routine thoracic procedures, but it can also occur accidentally during procedures near the lung or thoracic cavity. Some IPs may be asymptomatic and go undiagnosed, or their diagnosis may be delayed.[2] The majority of iatrogenic pneumothoraces will resolve without complications, and patients will not require medical attention. A small percentage can, however, expand and have the potential to develop into a tension pneumothorax causing severe respiratory distress and mediastinal shift.[3, 4]

The incidence of IP ranges from 0.11% with mechanical ventilation to 2.68% with thoracentesis, according to an analysis of 7.5 million uniform hospital discharge abstracts from 2000.⁵ A 2010 systematic review of 24 studies that included 6605 patients suggested a 6.0% incidence of pneumothorax following thoracentesis.[3] The highest risk of IP is seen with computed tomography (CT)‐guided lung biopsy, with 1 series of 1098 biopsies showing a 42% incidence; chest tube evacuation was required in 12% of these cases.[4] A Veterans Administration study of patient safety indicators from 2001 to 2004 found that risk‐adjusted rates of IP were increasing over time.[6] It is unclear whether this increase is due to increasing numbers of interventional procedures or to better rates of detection. IP poses a considerable cost to the medical system, with safety studies finding that patients with IP will stay in the hospital approximately 4 days longer and incur an additional $17,000 in charges.[7]

In addition to this financial burden, the lack of consistency in training and guidelines for management of pneumothorax is thought to add to chest tube‐related complications.[8] In 2001, the American College of Chest Physicians (ACCP) published guidelines for the management of spontaneous pneumothorax that do not specifically address IP.[9] In 2010, the British Thoracic Society (BTS) updated their guidelines and included a brief statement on IP that described a higher incidence for it than for spontaneous pneumothorax and noted its relative ease of management.[10] Despite the lack of specific guidelines dedicated to IPs, common clinical practice is to manage iatrogenic defects in a manner similar to that for spontaneous ones. However, studies have shown that the management of pneumothorax remains diverse and that the adherence to these published guidelines is suboptimal.[10, 11] The BTS guidelines favor needle aspiration as the first‐line treatment,[10] whereas the ACCP recommends drainage with catheters over aspiration.[9]

The possibility of this complication, along with the rising rate of invasive interventions being performed, has led to expanded surveillance criteria for IP. Surveillance imaging, clinical observation, or a combination of the 2 may be required, depending on the institution, the risk of the procedure, and the preference of the treating clinician. The algorithms presented here were designed in alignment with both major society guidelines and with the intention of simplifying the treatment regimen for the ease of adoption by hospitalists.

ETIOLOGY AND RISK FACTORS

The etiology and risk factors for IP are multiple, with the most common being interventional‐based procedures. In 535 Veterans Administration patients, the most common precursor procedures were transthoracic needle biopsy (24%), subclavian vein catheterization (22%), thoracentesis (20%), transbronchial biopsy (10%), pleural biopsy (8%), and positive pressure ventilation.[12] IP can also be a rare complication of pacemaker manipulations,[5] and less commonly, bronchoscopy.[13] Patient factors that increase the risk of pneumothorax in the setting of an intervention include age, chronic obstructive lung disease, primary lung cancer, malignant and parapneumonic pleural effusions, empyema, and chronic corticosteroid use.[4] As might be expected, patients with structural lung disease (eg, emphysema with bullae) and poor healing ability (eg, corticosteroid dependent), tend to have IPs more often and to require more complicated interventions for resolution.[14, 15] In some studies, operator experience seems to be inversely related to the rate of IP, and the use of ultrasound is correlated with lower rates of this complication.[1, 3]

PATIENT PRESENTATIONS AND DIAGNOSIS

Clinical signs and symptoms of a significant pneumothorax vary in severity but most often include dyspnea, tachypnea, chest pain, and pleurisy (see Box 1). Post procedure signs or symptoms require further evaluation with imaging, usually a plain chest radiograph. CT can be useful for further evaluation. Small anterior pneumothoraces may be difficult to detect without lateral radiographic imaging or computed tomogram. Ultrasound is being used more frequently at the bedside to make this diagnosis, and various studies of trauma patients have found that it has good sensitivity and specificity.[16, 17] These results have been validated by a recent meta‐analysis comparing ultrasound to chest radiographs for the detection of pneumothorax among trauma, critically ill, and postprocedural patients.[18] This study demonstrated superior sensitivity and similar specificity for ultrasound versus chest radiographs for detection of pneumothorax. More ominous signs, such as tachycardia or hypotension, can be indicative of tension pneumothorax, which requires emergent evacuation.

MANAGEMENT

Once the diagnosis of pneumothorax has been established, treatment options should be guided by defect size and clinical assessment following a defined treatment algorithm (Figure 1). As emphasized by the BTS and ACCP guidelines, we advocate considering the use of symptoms along with defect size to determine the best management course.

Figure 1

Placement of Catheter or Chest Tube Drainage

Most patients with a clinically significant pneumothorax will require evacuation of the air. Pneumothoraces larger than 20% or that produce symptoms warrant chest tube management and inpatient observation (Figure 1B). Traditionally, large tubes with 20 cm of water on continuous suction are used and have been studied the most widely. Several authors have shown that smaller tubes can effectively drain a pneumothorax.[26, 27, 28, 29] Small‐bore catheters (8F14F), which can be inserted percutaneously, have been shown to provide effective lung re‐expansion with minimal morbidity[8] and may be better tolerated by patients with uncomplicated pneumothoraces (Figure 2). Terzi and colleagues[30] have shown that smaller tubes cause less discomfort to patients at rest, with cough, and at the time of tube removal.

Figure 2

At most US institutions, catheters and chest tubes are connected to all‐purpose drainage systems. Although commercially available through a variety of manufacturers, they share similar design principles because they replicate the 3‐bottle system described in detail elsewhere in the literature.[31] We have limited our discussion to 3 pleural evacuation systems because it is our intention to familiarize hospitalists with the units that they are most likely to encounter. The first 2 systems have been studied and described by Baumann and colleagues[32] as being commonplace and reasonably reliable. These include the Oasis (Atrium Medical Corp., Hudson, NH) (Figure 3A) and the Pleur‐evac (Teleflex Inc., Limerick, PA). The third unit is the Thopaz digital thoracic drainage system (Medela Inc., McHenry, IL) (Figure 3B). The Thopaz is unique in its inclusion of a suction source and digital capability. Although it utilizes the same principles of all pleural evacuation devices, its setup and information output require that one be familiar with its digital format.

Figure 3

Assessing for Air Leak

If there is improvement or resolution of the pneumothorax after 24 hours, the presence of an air leak should be assessed; if no leak is present, the chest tube can be safely removed. In the context of chest tubes, the term air leak refers to residual air between the lung and the chest wall. It is possible to see resolution of a pneumothorax on chest radiographs and still have an air leak. This situation is created by a perfect balance between the pleural air evacuation by the catheter and the flow of air exiting from the lung puncture. This would result in reaccumulation of the pneumothorax if the chest tube is removed prematurely. It should also be kept in mind that chest radiographs may miss a small pneumothorax given their relatively low sensitivity.[18] Therefore, the absence of an air leak needs to be documented before the chest tube is discontinued. Depending on the type of drainage system (Atrium, Pleur‐evac, or Thopaz), this assessment can be done in several ways. All systems can be assessed for air leak by clamping the actual chest tube for 2 to 4 hours and then repeating the chest radiograph. Clamping a chest tube simulates the condition of not having a chest tube. Chest tubes should never be clamped without supervision and only with the knowledge of nursing personnel. The onset of chest pain or dyspnea in a patient with a clamped tube mandates immediate removal of the clamp and a return to suction. A repeat chest radiograph showing reaccumulation or expansion of the pneumothorax after clamping indicates that the air leak has not resolved and the chest tube must remain in place and returned to suction. Simpler and more time‐efficient methods of detecting air leaks are available with both cardiothoracic drainage systems.

For the Atrium and Pleur‐evac models, there is a graded panel through which one can visualize air leaks being funneled through water (Figure 4A). Having the patient cough several times or perform a Valsalva maneuver should release any air trapped within the chest into this chamber, where bubbles can be visualized as they travel through the water. The presence of bubbles indicates the presence of residual air in the chest, pointing to a possible leak. In contrast, the Thopaz system offers a graphical display of the air flowing into the system that can be reviewed over the 24‐hour period. When the graph line reaches a 0 flatline graph, no airflow is being detected and no air leakage is suspected (Figure 4B). If no air leaks are detected, the chest tube may be discontinued. Those patients with a failed air leak test should have their chest tubes continued under suction for another 24 hours, with the above tests then repeated. The same holds true for those patients with persistent pneumothorax at 24 hours.

Figure 4

Removal of chest tubes is a simple process that requires the tube to be pulled out of the patient without allowing air to enter the site where the tube was present and where it entered the thorax. Most interventionalists will discontinue the tubes that they have placed. Some small catheters have an internal string that has to be released so the catheter will straighten and pull out easily. Knowledge of the type of catheter or tube that was placed is critical before removal to prevent complications and patient discomfort. Standard chest tubes are straight, smooth plastic and pull out easily but require rapid occlusion of the larger puncture site in the chest wall with an occlusive dressing that often includes petroleum or water‐soluble gel. Some physicians will leave a suture tie when placing the chest tube so that it can be tied down to occlude the site instead of using a dressing.

PRACTICAL TIPS

Hospitalists caring for patients with chest tubes are often asked to troubleshoot at the bedside. Scenarios that may be encountered include nonfunctioning tubes, catheter migration, and tube discomfort. Ensuring patency of the tube entails visualizing the tube from the point of entry into the chest wall to the collection chamber and inspecting for kinks or debris clogging the tube. Smaller catheters can be easily kinked during patient positioning and can become clogged. Respiratory variation, which is the movement of the column of fluid in the collection chamber or in the tubing with inspiration and expiration, suggests that the chest tube is patent. This should be part of the daily examination in a patient with a chest tube, and it should also be the first step in assessing sudden dyspnea, hypoxia, pain, or hemodynamic instability. Clogged tubes should be referred to the interventionalists or other physicians who placed them. Chest tubes are typically sutured at the site of entry and securely bandaged to avoid migration but occasionally can be dislodged. This should prompt placement of another tube by an experienced operator. Last, chest tubes can be uncomfortable for patients who may require systemic analgesics. Additionally, tube positioning may ease some of the discomfort. Chest tubes are commonly placed along the midaxillary line and the posterior thorax, leading to discomfort in the recumbent position. Directing the tube anteriorly helps ease some of the discomfort. This can be done using all‐purpose sponges to build a barrier between the skin and the chest tube as it is directed anteriorly. Additional sponges are placed above the tube for extra protection. The gentle curve accomplished by padding the underside of the tube also keeps the tube patent by avoiding sharp kinks as the catheter exits the thorax.

FUTURE TRENDS

Future trends in the management of IP may include shorter duration of tube management (14 hours of suction with air leak evaluation and removal) and the use of even smaller catheters. Outpatient management of IP with small pigtail catheters or small‐caliber tubes in addition to 1‐way valves is also being investigated. The benefits of these practices may include greater patient comfort and lower cost. These approaches will need larger‐scale replication and careful patient selection before they become standard practice.[28, 36]

Ultrasound can be used to assess the presence and size of pneumothoraces that are difficult to visualize by standard chest radiographs. Several studies have established ultrasonography as an effective method of diagnosing pneumothorax and have shown it to have superior sensitivity compared with chest radiography.[1, 18] In the future, the use of ultrasound will likely be more widespread given its performance, portability, ease of use, and relatively low cost.

SUMMARY

IP is a known and costly complication of many medical procedures. The aforementioned algorithms help simplify the management of chest tubes for hospitalists caring for patients with this common complication. This stepwise approach may not only help curtail added expenses related to IPs by decreasing the length of inpatient stays but may also improve patient satisfaction.

A pneumothorax is a collection of air in the space outside the lungs that is trapped within the thorax. This abnormality can occur spontaneously or as the result of trauma. Traumatic pneumothoraces include those resulting from medical interventions such as a transthoracic and transbronchial needle biopsy, central line placement, and positive‐pressure mechanical ventilation. This group is most accurately described as iatrogenic pneumothorax (IP).[1]

IP can be an expected complication of many routine thoracic procedures, but it can also occur accidentally during procedures near the lung or thoracic cavity. Some IPs may be asymptomatic and go undiagnosed, or their diagnosis may be delayed.[2] The majority of iatrogenic pneumothoraces will resolve without complications, and patients will not require medical attention. A small percentage can, however, expand and have the potential to develop into a tension pneumothorax causing severe respiratory distress and mediastinal shift.[3, 4]

The incidence of IP ranges from 0.11% with mechanical ventilation to 2.68% with thoracentesis, according to an analysis of 7.5 million uniform hospital discharge abstracts from 2000.⁵ A 2010 systematic review of 24 studies that included 6605 patients suggested a 6.0% incidence of pneumothorax following thoracentesis.[3] The highest risk of IP is seen with computed tomography (CT)‐guided lung biopsy, with 1 series of 1098 biopsies showing a 42% incidence; chest tube evacuation was required in 12% of these cases.[4] A Veterans Administration study of patient safety indicators from 2001 to 2004 found that risk‐adjusted rates of IP were increasing over time.[6] It is unclear whether this increase is due to increasing numbers of interventional procedures or to better rates of detection. IP poses a considerable cost to the medical system, with safety studies finding that patients with IP will stay in the hospital approximately 4 days longer and incur an additional $17,000 in charges.[7]

In addition to this financial burden, the lack of consistency in training and guidelines for management of pneumothorax is thought to add to chest tube‐related complications.[8] In 2001, the American College of Chest Physicians (ACCP) published guidelines for the management of spontaneous pneumothorax that do not specifically address IP.[9] In 2010, the British Thoracic Society (BTS) updated their guidelines and included a brief statement on IP that described a higher incidence for it than for spontaneous pneumothorax and noted its relative ease of management.[10] Despite the lack of specific guidelines dedicated to IPs, common clinical practice is to manage iatrogenic defects in a manner similar to that for spontaneous ones. However, studies have shown that the management of pneumothorax remains diverse and that the adherence to these published guidelines is suboptimal.[10, 11] The BTS guidelines favor needle aspiration as the first‐line treatment,[10] whereas the ACCP recommends drainage with catheters over aspiration.[9]

The possibility of this complication, along with the rising rate of invasive interventions being performed, has led to expanded surveillance criteria for IP. Surveillance imaging, clinical observation, or a combination of the 2 may be required, depending on the institution, the risk of the procedure, and the preference of the treating clinician. The algorithms presented here were designed in alignment with both major society guidelines and with the intention of simplifying the treatment regimen for the ease of adoption by hospitalists.

ETIOLOGY AND RISK FACTORS

The etiology and risk factors for IP are multiple, with the most common being interventional‐based procedures. In 535 Veterans Administration patients, the most common precursor procedures were transthoracic needle biopsy (24%), subclavian vein catheterization (22%), thoracentesis (20%), transbronchial biopsy (10%), pleural biopsy (8%), and positive pressure ventilation.[12] IP can also be a rare complication of pacemaker manipulations,[5] and less commonly, bronchoscopy.[13] Patient factors that increase the risk of pneumothorax in the setting of an intervention include age, chronic obstructive lung disease, primary lung cancer, malignant and parapneumonic pleural effusions, empyema, and chronic corticosteroid use.[4] As might be expected, patients with structural lung disease (eg, emphysema with bullae) and poor healing ability (eg, corticosteroid dependent), tend to have IPs more often and to require more complicated interventions for resolution.[14, 15] In some studies, operator experience seems to be inversely related to the rate of IP, and the use of ultrasound is correlated with lower rates of this complication.[1, 3]

PATIENT PRESENTATIONS AND DIAGNOSIS

Clinical signs and symptoms of a significant pneumothorax vary in severity but most often include dyspnea, tachypnea, chest pain, and pleurisy (see Box 1). Post procedure signs or symptoms require further evaluation with imaging, usually a plain chest radiograph. CT can be useful for further evaluation. Small anterior pneumothoraces may be difficult to detect without lateral radiographic imaging or computed tomogram. Ultrasound is being used more frequently at the bedside to make this diagnosis, and various studies of trauma patients have found that it has good sensitivity and specificity.[16, 17] These results have been validated by a recent meta‐analysis comparing ultrasound to chest radiographs for the detection of pneumothorax among trauma, critically ill, and postprocedural patients.[18] This study demonstrated superior sensitivity and similar specificity for ultrasound versus chest radiographs for detection of pneumothorax. More ominous signs, such as tachycardia or hypotension, can be indicative of tension pneumothorax, which requires emergent evacuation.

MANAGEMENT

Once the diagnosis of pneumothorax has been established, treatment options should be guided by defect size and clinical assessment following a defined treatment algorithm (Figure 1). As emphasized by the BTS and ACCP guidelines, we advocate considering the use of symptoms along with defect size to determine the best management course.

Figure 1

Placement of Catheter or Chest Tube Drainage

Most patients with a clinically significant pneumothorax will require evacuation of the air. Pneumothoraces larger than 20% or that produce symptoms warrant chest tube management and inpatient observation (Figure 1B). Traditionally, large tubes with 20 cm of water on continuous suction are used and have been studied the most widely. Several authors have shown that smaller tubes can effectively drain a pneumothorax.[26, 27, 28, 29] Small‐bore catheters (8F14F), which can be inserted percutaneously, have been shown to provide effective lung re‐expansion with minimal morbidity[8] and may be better tolerated by patients with uncomplicated pneumothoraces (Figure 2). Terzi and colleagues[30] have shown that smaller tubes cause less discomfort to patients at rest, with cough, and at the time of tube removal.

Figure 2

At most US institutions, catheters and chest tubes are connected to all‐purpose drainage systems. Although commercially available through a variety of manufacturers, they share similar design principles because they replicate the 3‐bottle system described in detail elsewhere in the literature.[31] We have limited our discussion to 3 pleural evacuation systems because it is our intention to familiarize hospitalists with the units that they are most likely to encounter. The first 2 systems have been studied and described by Baumann and colleagues[32] as being commonplace and reasonably reliable. These include the Oasis (Atrium Medical Corp., Hudson, NH) (Figure 3A) and the Pleur‐evac (Teleflex Inc., Limerick, PA). The third unit is the Thopaz digital thoracic drainage system (Medela Inc., McHenry, IL) (Figure 3B). The Thopaz is unique in its inclusion of a suction source and digital capability. Although it utilizes the same principles of all pleural evacuation devices, its setup and information output require that one be familiar with its digital format.

Figure 3

Assessing for Air Leak

If there is improvement or resolution of the pneumothorax after 24 hours, the presence of an air leak should be assessed; if no leak is present, the chest tube can be safely removed. In the context of chest tubes, the term air leak refers to residual air between the lung and the chest wall. It is possible to see resolution of a pneumothorax on chest radiographs and still have an air leak. This situation is created by a perfect balance between the pleural air evacuation by the catheter and the flow of air exiting from the lung puncture. This would result in reaccumulation of the pneumothorax if the chest tube is removed prematurely. It should also be kept in mind that chest radiographs may miss a small pneumothorax given their relatively low sensitivity.[18] Therefore, the absence of an air leak needs to be documented before the chest tube is discontinued. Depending on the type of drainage system (Atrium, Pleur‐evac, or Thopaz), this assessment can be done in several ways. All systems can be assessed for air leak by clamping the actual chest tube for 2 to 4 hours and then repeating the chest radiograph. Clamping a chest tube simulates the condition of not having a chest tube. Chest tubes should never be clamped without supervision and only with the knowledge of nursing personnel. The onset of chest pain or dyspnea in a patient with a clamped tube mandates immediate removal of the clamp and a return to suction. A repeat chest radiograph showing reaccumulation or expansion of the pneumothorax after clamping indicates that the air leak has not resolved and the chest tube must remain in place and returned to suction. Simpler and more time‐efficient methods of detecting air leaks are available with both cardiothoracic drainage systems.

For the Atrium and Pleur‐evac models, there is a graded panel through which one can visualize air leaks being funneled through water (Figure 4A). Having the patient cough several times or perform a Valsalva maneuver should release any air trapped within the chest into this chamber, where bubbles can be visualized as they travel through the water. The presence of bubbles indicates the presence of residual air in the chest, pointing to a possible leak. In contrast, the Thopaz system offers a graphical display of the air flowing into the system that can be reviewed over the 24‐hour period. When the graph line reaches a 0 flatline graph, no airflow is being detected and no air leakage is suspected (Figure 4B). If no air leaks are detected, the chest tube may be discontinued. Those patients with a failed air leak test should have their chest tubes continued under suction for another 24 hours, with the above tests then repeated. The same holds true for those patients with persistent pneumothorax at 24 hours.

Figure 4

Removal of chest tubes is a simple process that requires the tube to be pulled out of the patient without allowing air to enter the site where the tube was present and where it entered the thorax. Most interventionalists will discontinue the tubes that they have placed. Some small catheters have an internal string that has to be released so the catheter will straighten and pull out easily. Knowledge of the type of catheter or tube that was placed is critical before removal to prevent complications and patient discomfort. Standard chest tubes are straight, smooth plastic and pull out easily but require rapid occlusion of the larger puncture site in the chest wall with an occlusive dressing that often includes petroleum or water‐soluble gel. Some physicians will leave a suture tie when placing the chest tube so that it can be tied down to occlude the site instead of using a dressing.

PRACTICAL TIPS

Hospitalists caring for patients with chest tubes are often asked to troubleshoot at the bedside. Scenarios that may be encountered include nonfunctioning tubes, catheter migration, and tube discomfort. Ensuring patency of the tube entails visualizing the tube from the point of entry into the chest wall to the collection chamber and inspecting for kinks or debris clogging the tube. Smaller catheters can be easily kinked during patient positioning and can become clogged. Respiratory variation, which is the movement of the column of fluid in the collection chamber or in the tubing with inspiration and expiration, suggests that the chest tube is patent. This should be part of the daily examination in a patient with a chest tube, and it should also be the first step in assessing sudden dyspnea, hypoxia, pain, or hemodynamic instability. Clogged tubes should be referred to the interventionalists or other physicians who placed them. Chest tubes are typically sutured at the site of entry and securely bandaged to avoid migration but occasionally can be dislodged. This should prompt placement of another tube by an experienced operator. Last, chest tubes can be uncomfortable for patients who may require systemic analgesics. Additionally, tube positioning may ease some of the discomfort. Chest tubes are commonly placed along the midaxillary line and the posterior thorax, leading to discomfort in the recumbent position. Directing the tube anteriorly helps ease some of the discomfort. This can be done using all‐purpose sponges to build a barrier between the skin and the chest tube as it is directed anteriorly. Additional sponges are placed above the tube for extra protection. The gentle curve accomplished by padding the underside of the tube also keeps the tube patent by avoiding sharp kinks as the catheter exits the thorax.

FUTURE TRENDS

Future trends in the management of IP may include shorter duration of tube management (14 hours of suction with air leak evaluation and removal) and the use of even smaller catheters. Outpatient management of IP with small pigtail catheters or small‐caliber tubes in addition to 1‐way valves is also being investigated. The benefits of these practices may include greater patient comfort and lower cost. These approaches will need larger‐scale replication and careful patient selection before they become standard practice.[28, 36]

Ultrasound can be used to assess the presence and size of pneumothoraces that are difficult to visualize by standard chest radiographs. Several studies have established ultrasonography as an effective method of diagnosing pneumothorax and have shown it to have superior sensitivity compared with chest radiography.[1, 18] In the future, the use of ultrasound will likely be more widespread given its performance, portability, ease of use, and relatively low cost.

SUMMARY

IP is a known and costly complication of many medical procedures. The aforementioned algorithms help simplify the management of chest tubes for hospitalists caring for patients with this common complication. This stepwise approach may not only help curtail added expenses related to IPs by decreasing the length of inpatient stays but may also improve patient satisfaction.

The implementation of resident duty hour restrictions has created a clinical learning environment on the wards quite different from any previous era. The Accreditation Council for Graduate Medical Education issued its first set of regulations limiting consecutive hours worked for residents in 2003, and further restricted hours in 2011.[1] These restrictions have had many implications across several aspects of patient care, education, and clinical training, particularly for hospitalists who spend the majority of their time in this setting and are heavily involved in undergraduate and graduate clinical education in academic medical centers.[2, 3]

As learning environments have been shifting, so has the composition of learners. The Millennial Generation (or Generation Y), defined as those born approximately between 1980 and 2000, represents those young clinicians currently filling the halls of medical schools and ranks of residency and fellowship programs.[4] Interestingly, the current system of restricted work hours is the only system under which the Millennial Generation has ever trained.

As this new generation represents the bulk of current trainees, hospitalist faculty must consider how their teaching styles can be adapted to accommodate these learners. For teaching hospitalists, an approach that considers the learning environment as affected by duty hours, as well as the preferences of Millennial learners, is necessary to educate the next generation of trainees. This article aimed to introduce potential strategies for hospitalists to better align teaching on the wards with the preferences of Millennial learners under the constraints of residency duty hours.

THE NEWEST GENERATION OF LEARNERS

The Millennial Generation has been well described.[4, 5, 6, 7, 8, 9, 10] Broadly speaking, this generation is thought to have been raised by attentive and involved parents, influencing relationships with educators and mentors; they respect authority but do not hesitate to question the relevance of assignments or decisions. Millennials prefer structured learning environments that focus heavily on interaction and experiential learning, and they value design and appearance in how material is presented.[7] Millennials also seek clear expectations and immediate feedback on their performance, and though they have sometimes been criticized for a strong sense of entitlement, they have a strong desire for collaboration and group‐based activity.[5, 6]

One of the most notable and defining characteristics of the Millennial Generation is an affinity for technology and innovation.[7, 8, 9] Web‐based learning tools that are interactive and engaging, such as blogs, podcasts, or streaming videos are familiar and favored methods of learning. Millennials are skilled at finding information and providing answers and data, but may need help with synthesis and application.[5] They take pride in their ability to multitask, but can be prone to doing so inappropriately, particularly with technology that is readily available.[11]

Few studies have explored characteristics of the Millennial Generation specific to medical trainees. One study examined personality characteristics of Millennial medical students compared to Generation X students (those born from 19651980) at a single institution. Millennial students scored higher on warmth, reasoning, emotional stability, rule consciousness, social boldness, sensitivity, apprehension, openness to change, and perfectionism compared to Generation X students. They scored lower on measures for self‐reliance.[12] Additionally, when motives for behavior were studied, Millennial medical students scored higher on needs for affiliation and achievement, and lower on needs for power.[13]

DUTY HOURS: A GENERATION APART

As noted previously, the Millennial Generation is the first to train exclusively in the era of duty hours restrictions. The oldest members of this generation, those born in 1981, were entering medical school at the time of the first duty hours restrictions in 2003, and thus have always been educated, trained, and practiced in an environment in which work hours were an essential part of residency training.

Though duty hours have been an omnipresent part of training for the Millennial Generation, the clinical learning environment that they have known continues to evolve and change. Time for teaching, in particular, has been especially strained by work hour limits, and this has been noted by both attending physicians and trainees with each iteration of work hours limits. Attendings in one study estimated that time spent teaching on general medicine wards was reduced by about 20% following the 2003 limits, and over 40% of residents in a national survey reported that the 2011 limits had worsened the quality of education.[14, 15]

GENERATIONAL STRATEGIES FOR SUCCESS FOR HOSPITALIST TEACHING ATTENDINGS

The time limitations imposed by duty hours restrictions have compelled teaching rounds to become more patient‐care centered and often less learner‐centered, as providing patient care becomes the prime obligation for this limited time period. Millennial learners are accustomed to being the center of attention in educational environments, and changing the focus from education to patient care in the wards setting may be an abrupt transition for some learners.[6] However, hospitalists can help restructure teaching opportunities on the clinical wards by using teaching methods of the highest value to Millennial learners to promote learning under the conditions of duty hours limitations.

An approach using these methods was developed by reviewing recent literature as well as educational innovations that have been presented at scholarly meetings (eg, Sal Khan's presentation at the 2012 Association of American Medical Colleges meeting).[16] The authors discussed potential teaching techniques that were thought to be feasible to implement in the context of the current learning environment, with consideration of learning theories that would be most effective for the target group of learners (eg, adult learning theory).[17] A mnemonic was created to consolidate strategies thought to best represent these techniques. FUTURE is a group of teaching strategies that can be used by hospitalists to improve teaching rounds by Flipping the Wards, Using Documentation to Teach, Technology‐Enabled Teaching, Using Guerilla Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments into Rounds.

ACCEPTING THE CHALLENGE

The landscape of clinical teaching has shifted considerably in recent years, in both the makeup of learners for whom educators are responsible for teaching as well as the challenges in teaching under the duty hours restrictions. Though rounds are more focused on patient care than in the past, it is possible to work within the current structure to promote successful learning with an approach that considers the preferences of today's learners.

A hospitalist's natural habitat, the busy inpatient wards, is a clinical learning environment with rich potential for innovation and excellence in teaching. The challenges in practicing hospital medicine closely parallel the challenges in teaching under the constraints of duty hours restrictions; both require a creative approach to problem solving and an affinity for teamwork. The hospitalist community is well suited to not only meet these challenges but become leaders in embracing how to teach effectively on today's wards. Maximizing interaction, embracing technology, and encouraging group‐based learning may represent the keys to a successful approach to teaching the Millennial Generation in a post‐duty hours world.

The implementation of resident duty hour restrictions has created a clinical learning environment on the wards quite different from any previous era. The Accreditation Council for Graduate Medical Education issued its first set of regulations limiting consecutive hours worked for residents in 2003, and further restricted hours in 2011.[1] These restrictions have had many implications across several aspects of patient care, education, and clinical training, particularly for hospitalists who spend the majority of their time in this setting and are heavily involved in undergraduate and graduate clinical education in academic medical centers.[2, 3]

As learning environments have been shifting, so has the composition of learners. The Millennial Generation (or Generation Y), defined as those born approximately between 1980 and 2000, represents those young clinicians currently filling the halls of medical schools and ranks of residency and fellowship programs.[4] Interestingly, the current system of restricted work hours is the only system under which the Millennial Generation has ever trained.

As this new generation represents the bulk of current trainees, hospitalist faculty must consider how their teaching styles can be adapted to accommodate these learners. For teaching hospitalists, an approach that considers the learning environment as affected by duty hours, as well as the preferences of Millennial learners, is necessary to educate the next generation of trainees. This article aimed to introduce potential strategies for hospitalists to better align teaching on the wards with the preferences of Millennial learners under the constraints of residency duty hours.

THE NEWEST GENERATION OF LEARNERS

The Millennial Generation has been well described.[4, 5, 6, 7, 8, 9, 10] Broadly speaking, this generation is thought to have been raised by attentive and involved parents, influencing relationships with educators and mentors; they respect authority but do not hesitate to question the relevance of assignments or decisions. Millennials prefer structured learning environments that focus heavily on interaction and experiential learning, and they value design and appearance in how material is presented.[7] Millennials also seek clear expectations and immediate feedback on their performance, and though they have sometimes been criticized for a strong sense of entitlement, they have a strong desire for collaboration and group‐based activity.[5, 6]

One of the most notable and defining characteristics of the Millennial Generation is an affinity for technology and innovation.[7, 8, 9] Web‐based learning tools that are interactive and engaging, such as blogs, podcasts, or streaming videos are familiar and favored methods of learning. Millennials are skilled at finding information and providing answers and data, but may need help with synthesis and application.[5] They take pride in their ability to multitask, but can be prone to doing so inappropriately, particularly with technology that is readily available.[11]

Few studies have explored characteristics of the Millennial Generation specific to medical trainees. One study examined personality characteristics of Millennial medical students compared to Generation X students (those born from 19651980) at a single institution. Millennial students scored higher on warmth, reasoning, emotional stability, rule consciousness, social boldness, sensitivity, apprehension, openness to change, and perfectionism compared to Generation X students. They scored lower on measures for self‐reliance.[12] Additionally, when motives for behavior were studied, Millennial medical students scored higher on needs for affiliation and achievement, and lower on needs for power.[13]

DUTY HOURS: A GENERATION APART

As noted previously, the Millennial Generation is the first to train exclusively in the era of duty hours restrictions. The oldest members of this generation, those born in 1981, were entering medical school at the time of the first duty hours restrictions in 2003, and thus have always been educated, trained, and practiced in an environment in which work hours were an essential part of residency training.

Though duty hours have been an omnipresent part of training for the Millennial Generation, the clinical learning environment that they have known continues to evolve and change. Time for teaching, in particular, has been especially strained by work hour limits, and this has been noted by both attending physicians and trainees with each iteration of work hours limits. Attendings in one study estimated that time spent teaching on general medicine wards was reduced by about 20% following the 2003 limits, and over 40% of residents in a national survey reported that the 2011 limits had worsened the quality of education.[14, 15]

GENERATIONAL STRATEGIES FOR SUCCESS FOR HOSPITALIST TEACHING ATTENDINGS

The time limitations imposed by duty hours restrictions have compelled teaching rounds to become more patient‐care centered and often less learner‐centered, as providing patient care becomes the prime obligation for this limited time period. Millennial learners are accustomed to being the center of attention in educational environments, and changing the focus from education to patient care in the wards setting may be an abrupt transition for some learners.[6] However, hospitalists can help restructure teaching opportunities on the clinical wards by using teaching methods of the highest value to Millennial learners to promote learning under the conditions of duty hours limitations.

An approach using these methods was developed by reviewing recent literature as well as educational innovations that have been presented at scholarly meetings (eg, Sal Khan's presentation at the 2012 Association of American Medical Colleges meeting).[16] The authors discussed potential teaching techniques that were thought to be feasible to implement in the context of the current learning environment, with consideration of learning theories that would be most effective for the target group of learners (eg, adult learning theory).[17] A mnemonic was created to consolidate strategies thought to best represent these techniques. FUTURE is a group of teaching strategies that can be used by hospitalists to improve teaching rounds by Flipping the Wards, Using Documentation to Teach, Technology‐Enabled Teaching, Using Guerilla Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments into Rounds.

ACCEPTING THE CHALLENGE

The landscape of clinical teaching has shifted considerably in recent years, in both the makeup of learners for whom educators are responsible for teaching as well as the challenges in teaching under the duty hours restrictions. Though rounds are more focused on patient care than in the past, it is possible to work within the current structure to promote successful learning with an approach that considers the preferences of today's learners.

A hospitalist's natural habitat, the busy inpatient wards, is a clinical learning environment with rich potential for innovation and excellence in teaching. The challenges in practicing hospital medicine closely parallel the challenges in teaching under the constraints of duty hours restrictions; both require a creative approach to problem solving and an affinity for teamwork. The hospitalist community is well suited to not only meet these challenges but become leaders in embracing how to teach effectively on today's wards. Maximizing interaction, embracing technology, and encouraging group‐based learning may represent the keys to a successful approach to teaching the Millennial Generation in a post‐duty hours world.

The implementation of resident duty hour restrictions has created a clinical learning environment on the wards quite different from any previous era. The Accreditation Council for Graduate Medical Education issued its first set of regulations limiting consecutive hours worked for residents in 2003, and further restricted hours in 2011.[1] These restrictions have had many implications across several aspects of patient care, education, and clinical training, particularly for hospitalists who spend the majority of their time in this setting and are heavily involved in undergraduate and graduate clinical education in academic medical centers.[2, 3]

As learning environments have been shifting, so has the composition of learners. The Millennial Generation (or Generation Y), defined as those born approximately between 1980 and 2000, represents those young clinicians currently filling the halls of medical schools and ranks of residency and fellowship programs.[4] Interestingly, the current system of restricted work hours is the only system under which the Millennial Generation has ever trained.

As this new generation represents the bulk of current trainees, hospitalist faculty must consider how their teaching styles can be adapted to accommodate these learners. For teaching hospitalists, an approach that considers the learning environment as affected by duty hours, as well as the preferences of Millennial learners, is necessary to educate the next generation of trainees. This article aimed to introduce potential strategies for hospitalists to better align teaching on the wards with the preferences of Millennial learners under the constraints of residency duty hours.

THE NEWEST GENERATION OF LEARNERS

The Millennial Generation has been well described.[4, 5, 6, 7, 8, 9, 10] Broadly speaking, this generation is thought to have been raised by attentive and involved parents, influencing relationships with educators and mentors; they respect authority but do not hesitate to question the relevance of assignments or decisions. Millennials prefer structured learning environments that focus heavily on interaction and experiential learning, and they value design and appearance in how material is presented.[7] Millennials also seek clear expectations and immediate feedback on their performance, and though they have sometimes been criticized for a strong sense of entitlement, they have a strong desire for collaboration and group‐based activity.[5, 6]

One of the most notable and defining characteristics of the Millennial Generation is an affinity for technology and innovation.[7, 8, 9] Web‐based learning tools that are interactive and engaging, such as blogs, podcasts, or streaming videos are familiar and favored methods of learning. Millennials are skilled at finding information and providing answers and data, but may need help with synthesis and application.[5] They take pride in their ability to multitask, but can be prone to doing so inappropriately, particularly with technology that is readily available.[11]

Few studies have explored characteristics of the Millennial Generation specific to medical trainees. One study examined personality characteristics of Millennial medical students compared to Generation X students (those born from 19651980) at a single institution. Millennial students scored higher on warmth, reasoning, emotional stability, rule consciousness, social boldness, sensitivity, apprehension, openness to change, and perfectionism compared to Generation X students. They scored lower on measures for self‐reliance.[12] Additionally, when motives for behavior were studied, Millennial medical students scored higher on needs for affiliation and achievement, and lower on needs for power.[13]

DUTY HOURS: A GENERATION APART

As noted previously, the Millennial Generation is the first to train exclusively in the era of duty hours restrictions. The oldest members of this generation, those born in 1981, were entering medical school at the time of the first duty hours restrictions in 2003, and thus have always been educated, trained, and practiced in an environment in which work hours were an essential part of residency training.

Though duty hours have been an omnipresent part of training for the Millennial Generation, the clinical learning environment that they have known continues to evolve and change. Time for teaching, in particular, has been especially strained by work hour limits, and this has been noted by both attending physicians and trainees with each iteration of work hours limits. Attendings in one study estimated that time spent teaching on general medicine wards was reduced by about 20% following the 2003 limits, and over 40% of residents in a national survey reported that the 2011 limits had worsened the quality of education.[14, 15]

GENERATIONAL STRATEGIES FOR SUCCESS FOR HOSPITALIST TEACHING ATTENDINGS

The time limitations imposed by duty hours restrictions have compelled teaching rounds to become more patient‐care centered and often less learner‐centered, as providing patient care becomes the prime obligation for this limited time period. Millennial learners are accustomed to being the center of attention in educational environments, and changing the focus from education to patient care in the wards setting may be an abrupt transition for some learners.[6] However, hospitalists can help restructure teaching opportunities on the clinical wards by using teaching methods of the highest value to Millennial learners to promote learning under the conditions of duty hours limitations.

An approach using these methods was developed by reviewing recent literature as well as educational innovations that have been presented at scholarly meetings (eg, Sal Khan's presentation at the 2012 Association of American Medical Colleges meeting).[16] The authors discussed potential teaching techniques that were thought to be feasible to implement in the context of the current learning environment, with consideration of learning theories that would be most effective for the target group of learners (eg, adult learning theory).[17] A mnemonic was created to consolidate strategies thought to best represent these techniques. FUTURE is a group of teaching strategies that can be used by hospitalists to improve teaching rounds by Flipping the Wards, Using Documentation to Teach, Technology‐Enabled Teaching, Using Guerilla Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments into Rounds.

ACCEPTING THE CHALLENGE

The landscape of clinical teaching has shifted considerably in recent years, in both the makeup of learners for whom educators are responsible for teaching as well as the challenges in teaching under the duty hours restrictions. Though rounds are more focused on patient care than in the past, it is possible to work within the current structure to promote successful learning with an approach that considers the preferences of today's learners.

A hospitalist's natural habitat, the busy inpatient wards, is a clinical learning environment with rich potential for innovation and excellence in teaching. The challenges in practicing hospital medicine closely parallel the challenges in teaching under the constraints of duty hours restrictions; both require a creative approach to problem solving and an affinity for teamwork. The hospitalist community is well suited to not only meet these challenges but become leaders in embracing how to teach effectively on today's wards. Maximizing interaction, embracing technology, and encouraging group‐based learning may represent the keys to a successful approach to teaching the Millennial Generation in a post‐duty hours world.

Healthcare spending exceeded $2.5 trillion in 2007, and payments to hospitals represented the largest portion of this spending (more than 30%), equaling the combined cost of physician services and prescription drugs.[1, 2] Researchers and policymakers have emphasized the need to improve the value of hospital care in the United States, but this has been challenging, in part because of the difficulty in identifying hospitals that have high resource utilization relative to their peers.[3, 4, 5, 6, 7, 8, 9, 10, 11]

Most hospitals calculate their costs using internal accounting systems that determine resource utilization via relative value units (RVUs).[7, 8] RVU‐derived costs, also known as hospital reported costs, have proven to be an excellent method for quantifying what it costs a given hospital to provide a treatment, test, or procedure. However, RVU‐based costs are less useful for comparing resource utilization across hospitals because the cost to provide a treatment or service varies widely across hospitals. The cost of an item calculated using RVUs includes not just the item itself, but also a portion of the fixed costs of the hospital (overhead, labor, and infrastructure investments such as electronic records, new buildings, or expensive radiological or surgical equipment).[12] These costs vary by institution, patient population, region of the country, teaching status, and many other variables, making it difficult to identify resource utilization across hospitals.[13, 14]

Recently, a few claims‐based multi‐institutional datasets have begun incorporating item‐level RVU‐based costs derived directly from the cost accounting systems of participating institutions.[15] Such datasets allow researchers to compare reported costs of care from hospital to hospital, but because of the limitations we described above, they still cannot be used to answer the question: Which hospitals with higher costs of care are actually providing more treatments and services to patients?

To better facilitate the comparison of resource utilization patterns across hospitals, we standardized the unit costs of all treatments and services across hospitals by applying a single cost to every item across hospitals. This standardized cost allowed to compare utilization of that item (and the 15,000 other items in the database) across hospitals. We then compared estimates of resource utilization as measured by the 2 approaches: standardized and RVU‐based costs.

METHODS

Assignment of Standardized Costs

We defined reported cost as the RVU‐based cost per item in the database. We then calculated the median across hospitals for each item in the database and set this as the standardized unit cost of that item at every hospital (Figure 1). Once standardized costs were assigned at the item level, we summed the costs of all items assigned to each patient and calculated the standardized cost of a hospitalization per patient at each hospital.

Figure 1

RESULTS

The 234 hospitals included in the analysis contributed a total of 165,647 hospitalizations, with the number of hospitalizations ranging from 33 to 2,772 hospitalizations per hospital (see Supporting Table 1 in the online version of this article). Most were located in urban areas (84%), and many were in the southern United States (42%). The median hospital reported cost per hospitalization was $6,535, with an interquartile range of $5,541 to $7,454. The median standardized cost per hospitalization was $6,602, with a range of $5,866 to $7,386. The interquartile ratio (Q75/Q25) of the reported costs of a hospitalization was 1.35. After costs were standardized, the interquartile ratio fell to 1.26, indicating that variation decreased. We found that the median hospital reported cost per day was $1,651, with an IQR of $1,400 to $1,933 (ratio 1.38), whereas the median standardized cost per day was $1,640, with an IQR of $1,511 to $1,812 (ratio 1.20).

There were more than 15,000 items (eg, treatments, tests, and supplies) that received a standardized charge code in our cohort. These were divided into 11 summary departments and 40 standard departments (see Supporting Table 2 in the online version of this article). We observed a high level of variation in the reported costs of individual items: the reported costs of a day of room and board in an ICU ranged from $773 at hospitals at the 10th percentile to $2,471 at the 90th percentile (Table 1.). The standardized cost of a day of ICU room and board was $1,577. We also observed variation in the reported costs of items across item categories. Although a day of medical room and board showed a 3‐fold difference between the 10th and 90th percentile, we observed a more than 10‐fold difference in the reported cost of an echocardiogram, from $31 at the 10th percentile to $356 at the 90th percentile. After examining the hospital‐level cost for a basket of goods, we found variation in the reported costs for these items across hospitals, with a 10th percentile cost of $1,552 and a 90th percentile cost of $3,967.

We found that 46 (20%) hospitals had reported costs of hospitalizations that were 25% greater than standardized costs (Figure 2). This group of hospitals had overestimated reported costs of utilization; 146 (62%) had reported costs within 25% of standardized costs, and 42 (17%) had reported costs that were 25% less than standardized costs (indicating that reported costs underestimated utilization). We examined the relationship between hospital characteristics and strata and found no significant association between the reported to standardized cost ratio and number of beds, teaching status, or urban location (Table 2). Hospitals in the Midwest and South were more likely to have a lower reported cost of hospitalizations, whereas hospitals in the West were more likely to have higher reported costs (P<0.001). When using the CV to compare reported costs to standardized costs, we found that per‐day standardized costs showed reduced variance (P=0.0238), but there was no significant difference in variance of the reported and standardized costs when examining the entire hospitalization (P=0.1423). At the level of the hospitalization, the Spearman correlation coefficient between reported and standardized cost was 0.89.

Figure 2

To better understand how hospitals can achieve high reported costs through different mechanisms, we more closely examined 3 hospitals with similar reported costs (Figure 3). These hospitals represented low, average, and high utilization according to their standardized costs, but had similar average per‐hospitalization reported costs: $11,643, $11,787, and $11,892, respectively. The corresponding standardized costs were $8,757, $11,169, and $15,978. The hospital with high utilization ($15,978 in standardized costs) was accounted for by increased use of supplies and other services. In contrast, the low‐ and average‐utilization hospitals had proportionally lower standardized costs across categories, with the greatest percentage of spending going toward room and board (includes nursing).

Figure 3

DISCUSSION

In a large national sample of hospitals, we observed variation in the reported costs for a uniform basket of goods, with a more than 2‐fold difference in cost between the 10th and 90th percentile hospitals. These findings suggest that reported costs have limited ability to reliably describe differences in utilization across hospitals. In contrast, when we applied standardized costs, the variance of per‐day costs decreased significantly, and the interquartile ratio of per‐day and hospitalization costs decreased as well, suggesting less variation in utilization across hospitals than would have been inferred from a comparison of reported costs. Applying a single, standard cost to all items can facilitate comparisons of utilization between hospitals (Figure 1). Standardized costs will give hospitals the potential to compare their utilization to their competitors and will facilitate research that examines the comparative effectiveness of high and low utilization in the management of medical and surgical conditions.

The reported to standardized cost ratio is another useful tool. It indicates whether the hospital's reported costs exaggerate its utilization relative to other hospitals. In this study, we found that a significant proportion of hospitals (20%) had reported costs that exceeded standardized costs by more than 25%. These hospitals have higher infrastructure, labor, or acquisition costs relative to their peers. To the extent that these hospitals might wish to lower the cost of care at their institution, they could focus on renegotiating purchasing or labor contracts, identifying areas where they may be overstaffed, or holding off on future infrastructure investments (Table 3).[14] In contrast, 17% of hospitals had reported costs that were 25% less than standardized costs. High‐cost hospitals in this group are therefore providing more treatments and testing to patients relative to their peers and could focus cost‐control efforts on reducing unnecessary utilization and duplicative testing.[20] Our examination of the hospital with high reported costs and very high utilization revealed a high percentage of supplies and other items, which is a category used primarily for nursing expenditures (Figure 3). Because the use of nursing services is directly related to days spent in the hospital, this hospital may wish to more closely examine specific strategies for reducing length of stay.

We did not find a consistent association between the reported to standardized cost ratio and hospital characteristics. This is an important finding that contradicts prior work examining associations between hospital characteristics and costs for heart failure patients,[21] further indicating the complexity of the relationship between fixed costs and variable costs and the difficulty in adjusting reported costs to calculate utilization. For example, small hospitals may have higher acquisition costs and more supply chain difficulties, but they may also have less technology, lower overhead costs, and fewer specialists to order tests and procedures. Hospital characteristics, such as urban location and teaching status, are commonly used as adjustors in cost studies because hospitals in urban areas with teaching missions (which often provide care to low‐income populations) are assumed to have higher fixed costs,[3, 4, 5, 6] but the lack of a consistent relationship between these characteristics and the standardized cost ratio may indicate that using these factors as adjustors for cost may not be effective and could even obscure differences in utilization between hospitals. Notably, we did find an association between hospital region and the reported to standardized cost ratio, but we hesitate to draw conclusions from this finding because the Premier database is imbalanced in terms of regional representation, with fewer hospitals in the Midwest and West and the bulk of the hospitals in the South.

Although standardized costs have great potential, this method has limitations as well. Standardized costs can only be applied when detailed billing data with item‐level costs are available. This is because calculation of standardized costs requires taking the median of item costs and applying the median cost across the database, maintaining the integrity of the relative cost of items to one another. The relative cost of items is preserved (ie, magnetic resonance imaging still costs more than an aspirin), which maintains the general scheme of RVU‐based costs while removing the noise of varying RVU‐based costs across hospitals.[7] Application of an arbitrary item cost would result in the loss of this relative cost difference. Because item costs are not available in traditional administrative datasets, these datasets would not be amenable to this method. However, highly detailed billing data are now being shared by hundreds of hospitals in the Premier network and the University Health System Consortium. These data are widely available to investigators, meaning that the generalizability of this method will only improve over time. It was also a limitation of the study that we chose a limited basket of items common to patients with heart failure to describe the range of reported costs and to provide a standardized snapshot by which to compare hospitals. Because we only included a few items, we may have overestimated or underestimated the range of reported costs for such a basket.

Standardized costs are a novel method for comparing utilization across hospitals. Used properly, they will help identify high‐ and low‐intensity providers of hospital care.

Healthcare spending exceeded $2.5 trillion in 2007, and payments to hospitals represented the largest portion of this spending (more than 30%), equaling the combined cost of physician services and prescription drugs.[1, 2] Researchers and policymakers have emphasized the need to improve the value of hospital care in the United States, but this has been challenging, in part because of the difficulty in identifying hospitals that have high resource utilization relative to their peers.[3, 4, 5, 6, 7, 8, 9, 10, 11]

Most hospitals calculate their costs using internal accounting systems that determine resource utilization via relative value units (RVUs).[7, 8] RVU‐derived costs, also known as hospital reported costs, have proven to be an excellent method for quantifying what it costs a given hospital to provide a treatment, test, or procedure. However, RVU‐based costs are less useful for comparing resource utilization across hospitals because the cost to provide a treatment or service varies widely across hospitals. The cost of an item calculated using RVUs includes not just the item itself, but also a portion of the fixed costs of the hospital (overhead, labor, and infrastructure investments such as electronic records, new buildings, or expensive radiological or surgical equipment).[12] These costs vary by institution, patient population, region of the country, teaching status, and many other variables, making it difficult to identify resource utilization across hospitals.[13, 14]

Recently, a few claims‐based multi‐institutional datasets have begun incorporating item‐level RVU‐based costs derived directly from the cost accounting systems of participating institutions.[15] Such datasets allow researchers to compare reported costs of care from hospital to hospital, but because of the limitations we described above, they still cannot be used to answer the question: Which hospitals with higher costs of care are actually providing more treatments and services to patients?

To better facilitate the comparison of resource utilization patterns across hospitals, we standardized the unit costs of all treatments and services across hospitals by applying a single cost to every item across hospitals. This standardized cost allowed to compare utilization of that item (and the 15,000 other items in the database) across hospitals. We then compared estimates of resource utilization as measured by the 2 approaches: standardized and RVU‐based costs.

METHODS

Assignment of Standardized Costs

We defined reported cost as the RVU‐based cost per item in the database. We then calculated the median across hospitals for each item in the database and set this as the standardized unit cost of that item at every hospital (Figure 1). Once standardized costs were assigned at the item level, we summed the costs of all items assigned to each patient and calculated the standardized cost of a hospitalization per patient at each hospital.

Figure 1

RESULTS

The 234 hospitals included in the analysis contributed a total of 165,647 hospitalizations, with the number of hospitalizations ranging from 33 to 2,772 hospitalizations per hospital (see Supporting Table 1 in the online version of this article). Most were located in urban areas (84%), and many were in the southern United States (42%). The median hospital reported cost per hospitalization was $6,535, with an interquartile range of $5,541 to $7,454. The median standardized cost per hospitalization was $6,602, with a range of $5,866 to $7,386. The interquartile ratio (Q75/Q25) of the reported costs of a hospitalization was 1.35. After costs were standardized, the interquartile ratio fell to 1.26, indicating that variation decreased. We found that the median hospital reported cost per day was $1,651, with an IQR of $1,400 to $1,933 (ratio 1.38), whereas the median standardized cost per day was $1,640, with an IQR of $1,511 to $1,812 (ratio 1.20).

There were more than 15,000 items (eg, treatments, tests, and supplies) that received a standardized charge code in our cohort. These were divided into 11 summary departments and 40 standard departments (see Supporting Table 2 in the online version of this article). We observed a high level of variation in the reported costs of individual items: the reported costs of a day of room and board in an ICU ranged from $773 at hospitals at the 10th percentile to $2,471 at the 90th percentile (Table 1.). The standardized cost of a day of ICU room and board was $1,577. We also observed variation in the reported costs of items across item categories. Although a day of medical room and board showed a 3‐fold difference between the 10th and 90th percentile, we observed a more than 10‐fold difference in the reported cost of an echocardiogram, from $31 at the 10th percentile to $356 at the 90th percentile. After examining the hospital‐level cost for a basket of goods, we found variation in the reported costs for these items across hospitals, with a 10th percentile cost of $1,552 and a 90th percentile cost of $3,967.

We found that 46 (20%) hospitals had reported costs of hospitalizations that were 25% greater than standardized costs (Figure 2). This group of hospitals had overestimated reported costs of utilization; 146 (62%) had reported costs within 25% of standardized costs, and 42 (17%) had reported costs that were 25% less than standardized costs (indicating that reported costs underestimated utilization). We examined the relationship between hospital characteristics and strata and found no significant association between the reported to standardized cost ratio and number of beds, teaching status, or urban location (Table 2). Hospitals in the Midwest and South were more likely to have a lower reported cost of hospitalizations, whereas hospitals in the West were more likely to have higher reported costs (P<0.001). When using the CV to compare reported costs to standardized costs, we found that per‐day standardized costs showed reduced variance (P=0.0238), but there was no significant difference in variance of the reported and standardized costs when examining the entire hospitalization (P=0.1423). At the level of the hospitalization, the Spearman correlation coefficient between reported and standardized cost was 0.89.

Figure 2

To better understand how hospitals can achieve high reported costs through different mechanisms, we more closely examined 3 hospitals with similar reported costs (Figure 3). These hospitals represented low, average, and high utilization according to their standardized costs, but had similar average per‐hospitalization reported costs: $11,643, $11,787, and $11,892, respectively. The corresponding standardized costs were $8,757, $11,169, and $15,978. The hospital with high utilization ($15,978 in standardized costs) was accounted for by increased use of supplies and other services. In contrast, the low‐ and average‐utilization hospitals had proportionally lower standardized costs across categories, with the greatest percentage of spending going toward room and board (includes nursing).

Figure 3

DISCUSSION

In a large national sample of hospitals, we observed variation in the reported costs for a uniform basket of goods, with a more than 2‐fold difference in cost between the 10th and 90th percentile hospitals. These findings suggest that reported costs have limited ability to reliably describe differences in utilization across hospitals. In contrast, when we applied standardized costs, the variance of per‐day costs decreased significantly, and the interquartile ratio of per‐day and hospitalization costs decreased as well, suggesting less variation in utilization across hospitals than would have been inferred from a comparison of reported costs. Applying a single, standard cost to all items can facilitate comparisons of utilization between hospitals (Figure 1). Standardized costs will give hospitals the potential to compare their utilization to their competitors and will facilitate research that examines the comparative effectiveness of high and low utilization in the management of medical and surgical conditions.

The reported to standardized cost ratio is another useful tool. It indicates whether the hospital's reported costs exaggerate its utilization relative to other hospitals. In this study, we found that a significant proportion of hospitals (20%) had reported costs that exceeded standardized costs by more than 25%. These hospitals have higher infrastructure, labor, or acquisition costs relative to their peers. To the extent that these hospitals might wish to lower the cost of care at their institution, they could focus on renegotiating purchasing or labor contracts, identifying areas where they may be overstaffed, or holding off on future infrastructure investments (Table 3).[14] In contrast, 17% of hospitals had reported costs that were 25% less than standardized costs. High‐cost hospitals in this group are therefore providing more treatments and testing to patients relative to their peers and could focus cost‐control efforts on reducing unnecessary utilization and duplicative testing.[20] Our examination of the hospital with high reported costs and very high utilization revealed a high percentage of supplies and other items, which is a category used primarily for nursing expenditures (Figure 3). Because the use of nursing services is directly related to days spent in the hospital, this hospital may wish to more closely examine specific strategies for reducing length of stay.

We did not find a consistent association between the reported to standardized cost ratio and hospital characteristics. This is an important finding that contradicts prior work examining associations between hospital characteristics and costs for heart failure patients,[21] further indicating the complexity of the relationship between fixed costs and variable costs and the difficulty in adjusting reported costs to calculate utilization. For example, small hospitals may have higher acquisition costs and more supply chain difficulties, but they may also have less technology, lower overhead costs, and fewer specialists to order tests and procedures. Hospital characteristics, such as urban location and teaching status, are commonly used as adjustors in cost studies because hospitals in urban areas with teaching missions (which often provide care to low‐income populations) are assumed to have higher fixed costs,[3, 4, 5, 6] but the lack of a consistent relationship between these characteristics and the standardized cost ratio may indicate that using these factors as adjustors for cost may not be effective and could even obscure differences in utilization between hospitals. Notably, we did find an association between hospital region and the reported to standardized cost ratio, but we hesitate to draw conclusions from this finding because the Premier database is imbalanced in terms of regional representation, with fewer hospitals in the Midwest and West and the bulk of the hospitals in the South.

Although standardized costs have great potential, this method has limitations as well. Standardized costs can only be applied when detailed billing data with item‐level costs are available. This is because calculation of standardized costs requires taking the median of item costs and applying the median cost across the database, maintaining the integrity of the relative cost of items to one another. The relative cost of items is preserved (ie, magnetic resonance imaging still costs more than an aspirin), which maintains the general scheme of RVU‐based costs while removing the noise of varying RVU‐based costs across hospitals.[7] Application of an arbitrary item cost would result in the loss of this relative cost difference. Because item costs are not available in traditional administrative datasets, these datasets would not be amenable to this method. However, highly detailed billing data are now being shared by hundreds of hospitals in the Premier network and the University Health System Consortium. These data are widely available to investigators, meaning that the generalizability of this method will only improve over time. It was also a limitation of the study that we chose a limited basket of items common to patients with heart failure to describe the range of reported costs and to provide a standardized snapshot by which to compare hospitals. Because we only included a few items, we may have overestimated or underestimated the range of reported costs for such a basket.

Standardized costs are a novel method for comparing utilization across hospitals. Used properly, they will help identify high‐ and low‐intensity providers of hospital care.

Healthcare spending exceeded $2.5 trillion in 2007, and payments to hospitals represented the largest portion of this spending (more than 30%), equaling the combined cost of physician services and prescription drugs.[1, 2] Researchers and policymakers have emphasized the need to improve the value of hospital care in the United States, but this has been challenging, in part because of the difficulty in identifying hospitals that have high resource utilization relative to their peers.[3, 4, 5, 6, 7, 8, 9, 10, 11]

Most hospitals calculate their costs using internal accounting systems that determine resource utilization via relative value units (RVUs).[7, 8] RVU‐derived costs, also known as hospital reported costs, have proven to be an excellent method for quantifying what it costs a given hospital to provide a treatment, test, or procedure. However, RVU‐based costs are less useful for comparing resource utilization across hospitals because the cost to provide a treatment or service varies widely across hospitals. The cost of an item calculated using RVUs includes not just the item itself, but also a portion of the fixed costs of the hospital (overhead, labor, and infrastructure investments such as electronic records, new buildings, or expensive radiological or surgical equipment).[12] These costs vary by institution, patient population, region of the country, teaching status, and many other variables, making it difficult to identify resource utilization across hospitals.[13, 14]

Recently, a few claims‐based multi‐institutional datasets have begun incorporating item‐level RVU‐based costs derived directly from the cost accounting systems of participating institutions.[15] Such datasets allow researchers to compare reported costs of care from hospital to hospital, but because of the limitations we described above, they still cannot be used to answer the question: Which hospitals with higher costs of care are actually providing more treatments and services to patients?

To better facilitate the comparison of resource utilization patterns across hospitals, we standardized the unit costs of all treatments and services across hospitals by applying a single cost to every item across hospitals. This standardized cost allowed to compare utilization of that item (and the 15,000 other items in the database) across hospitals. We then compared estimates of resource utilization as measured by the 2 approaches: standardized and RVU‐based costs.

METHODS

Assignment of Standardized Costs

We defined reported cost as the RVU‐based cost per item in the database. We then calculated the median across hospitals for each item in the database and set this as the standardized unit cost of that item at every hospital (Figure 1). Once standardized costs were assigned at the item level, we summed the costs of all items assigned to each patient and calculated the standardized cost of a hospitalization per patient at each hospital.

Figure 1

RESULTS

The 234 hospitals included in the analysis contributed a total of 165,647 hospitalizations, with the number of hospitalizations ranging from 33 to 2,772 hospitalizations per hospital (see Supporting Table 1 in the online version of this article). Most were located in urban areas (84%), and many were in the southern United States (42%). The median hospital reported cost per hospitalization was $6,535, with an interquartile range of $5,541 to $7,454. The median standardized cost per hospitalization was $6,602, with a range of $5,866 to $7,386. The interquartile ratio (Q75/Q25) of the reported costs of a hospitalization was 1.35. After costs were standardized, the interquartile ratio fell to 1.26, indicating that variation decreased. We found that the median hospital reported cost per day was $1,651, with an IQR of $1,400 to $1,933 (ratio 1.38), whereas the median standardized cost per day was $1,640, with an IQR of $1,511 to $1,812 (ratio 1.20).

There were more than 15,000 items (eg, treatments, tests, and supplies) that received a standardized charge code in our cohort. These were divided into 11 summary departments and 40 standard departments (see Supporting Table 2 in the online version of this article). We observed a high level of variation in the reported costs of individual items: the reported costs of a day of room and board in an ICU ranged from $773 at hospitals at the 10th percentile to $2,471 at the 90th percentile (Table 1.). The standardized cost of a day of ICU room and board was $1,577. We also observed variation in the reported costs of items across item categories. Although a day of medical room and board showed a 3‐fold difference between the 10th and 90th percentile, we observed a more than 10‐fold difference in the reported cost of an echocardiogram, from $31 at the 10th percentile to $356 at the 90th percentile. After examining the hospital‐level cost for a basket of goods, we found variation in the reported costs for these items across hospitals, with a 10th percentile cost of $1,552 and a 90th percentile cost of $3,967.

We found that 46 (20%) hospitals had reported costs of hospitalizations that were 25% greater than standardized costs (Figure 2). This group of hospitals had overestimated reported costs of utilization; 146 (62%) had reported costs within 25% of standardized costs, and 42 (17%) had reported costs that were 25% less than standardized costs (indicating that reported costs underestimated utilization). We examined the relationship between hospital characteristics and strata and found no significant association between the reported to standardized cost ratio and number of beds, teaching status, or urban location (Table 2). Hospitals in the Midwest and South were more likely to have a lower reported cost of hospitalizations, whereas hospitals in the West were more likely to have higher reported costs (P<0.001). When using the CV to compare reported costs to standardized costs, we found that per‐day standardized costs showed reduced variance (P=0.0238), but there was no significant difference in variance of the reported and standardized costs when examining the entire hospitalization (P=0.1423). At the level of the hospitalization, the Spearman correlation coefficient between reported and standardized cost was 0.89.

Figure 2

To better understand how hospitals can achieve high reported costs through different mechanisms, we more closely examined 3 hospitals with similar reported costs (Figure 3). These hospitals represented low, average, and high utilization according to their standardized costs, but had similar average per‐hospitalization reported costs: $11,643, $11,787, and $11,892, respectively. The corresponding standardized costs were $8,757, $11,169, and $15,978. The hospital with high utilization ($15,978 in standardized costs) was accounted for by increased use of supplies and other services. In contrast, the low‐ and average‐utilization hospitals had proportionally lower standardized costs across categories, with the greatest percentage of spending going toward room and board (includes nursing).

Figure 3

DISCUSSION

In a large national sample of hospitals, we observed variation in the reported costs for a uniform basket of goods, with a more than 2‐fold difference in cost between the 10th and 90th percentile hospitals. These findings suggest that reported costs have limited ability to reliably describe differences in utilization across hospitals. In contrast, when we applied standardized costs, the variance of per‐day costs decreased significantly, and the interquartile ratio of per‐day and hospitalization costs decreased as well, suggesting less variation in utilization across hospitals than would have been inferred from a comparison of reported costs. Applying a single, standard cost to all items can facilitate comparisons of utilization between hospitals (Figure 1). Standardized costs will give hospitals the potential to compare their utilization to their competitors and will facilitate research that examines the comparative effectiveness of high and low utilization in the management of medical and surgical conditions.

The reported to standardized cost ratio is another useful tool. It indicates whether the hospital's reported costs exaggerate its utilization relative to other hospitals. In this study, we found that a significant proportion of hospitals (20%) had reported costs that exceeded standardized costs by more than 25%. These hospitals have higher infrastructure, labor, or acquisition costs relative to their peers. To the extent that these hospitals might wish to lower the cost of care at their institution, they could focus on renegotiating purchasing or labor contracts, identifying areas where they may be overstaffed, or holding off on future infrastructure investments (Table 3).[14] In contrast, 17% of hospitals had reported costs that were 25% less than standardized costs. High‐cost hospitals in this group are therefore providing more treatments and testing to patients relative to their peers and could focus cost‐control efforts on reducing unnecessary utilization and duplicative testing.[20] Our examination of the hospital with high reported costs and very high utilization revealed a high percentage of supplies and other items, which is a category used primarily for nursing expenditures (Figure 3). Because the use of nursing services is directly related to days spent in the hospital, this hospital may wish to more closely examine specific strategies for reducing length of stay.