Expert Commentary

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

Urinary incontinence affects more than one-third of women aged 70 years or older. As the authors of this study point out, urinary incontinence is comparable to other chronic conditions, such as hypertension and diabetes mellitus, in its impact on quality of life, and is a common reason for institutionalization.

The risk of urinary incontinence increases with age. In elderly women, it is often mixed (ie, having both urge- and stress-related components) and associated with functional impairments, including reduced mobility. It is thought that the association between incontinence and functional impairment is related primarily to the urge component:

• Women with impaired mobility take longer to reach the toilet, increasing the risk of leakage when the urge to urinate is strong
• Women with urge incontinence may be more likely to limit their activities so that they are always near a toilet.

Cognitive impairment may also play a role, affecting motor skills and bladder control.

To better understand why advancing age is linked with urinary incontinence, Fritel and colleagues studied a population of 1,942 urban-dwelling French women aged 75 to 85 years (mean age, 79.3 years; mean body mass index, 25.9 kg/m²).

Details of the study
Investigators assessed the frequency and quantity of urine leaks, the impact of urinary incontinence on daily life, and the participants’ mobility and balance. Data on urinary incontinence were collected via a self-administered questionnaire (the International Consultation on Incontinence Questionnaire–Short Form). Motor-related physical function was assessed using standardized balance and gait tests.

Urinary incontinence was reported by 42% of participants. Of these women, 57% reported daily urine leakage, with mixed incontinence found to be more prevalent than urge incontinence, which was more prevalent than stress incontinence. Overall, women with urinary incontinence reported that its impact on daily life was mild. Among those with mixed or urge incontinence, limitations in mobility and balance were correlated significantly with the severity of incontinence.

What this evidence means for practice
These findings support earlier data suggesting that impaired mobility can promote urge and mixed urinary incontinence. Because there also is a possibility that cerebral deterioration in aging women causes gait and balance problems that increase the likelihood of urge incontinence, the authors advise against the use of anticholinergic agents in elderly women, as these drugs can impair cognitive function. Another take-home message from this French report is that we should counsel elderly patients about the importance of maintaining balance and mobility through exercise, physical therapy, or other strategies.
Andrew M. Kaunitz, MD

Urinary incontinence affects more than one-third of women aged 70 years or older. As the authors of this study point out, urinary incontinence is comparable to other chronic conditions, such as hypertension and diabetes mellitus, in its impact on quality of life, and is a common reason for institutionalization.

The risk of urinary incontinence increases with age. In elderly women, it is often mixed (ie, having both urge- and stress-related components) and associated with functional impairments, including reduced mobility. It is thought that the association between incontinence and functional impairment is related primarily to the urge component:

• Women with impaired mobility take longer to reach the toilet, increasing the risk of leakage when the urge to urinate is strong
• Women with urge incontinence may be more likely to limit their activities so that they are always near a toilet.

Cognitive impairment may also play a role, affecting motor skills and bladder control.

To better understand why advancing age is linked with urinary incontinence, Fritel and colleagues studied a population of 1,942 urban-dwelling French women aged 75 to 85 years (mean age, 79.3 years; mean body mass index, 25.9 kg/m²).

Details of the study
Investigators assessed the frequency and quantity of urine leaks, the impact of urinary incontinence on daily life, and the participants’ mobility and balance. Data on urinary incontinence were collected via a self-administered questionnaire (the International Consultation on Incontinence Questionnaire–Short Form). Motor-related physical function was assessed using standardized balance and gait tests.

Urinary incontinence was reported by 42% of participants. Of these women, 57% reported daily urine leakage, with mixed incontinence found to be more prevalent than urge incontinence, which was more prevalent than stress incontinence. Overall, women with urinary incontinence reported that its impact on daily life was mild. Among those with mixed or urge incontinence, limitations in mobility and balance were correlated significantly with the severity of incontinence.

What this evidence means for practice
These findings support earlier data suggesting that impaired mobility can promote urge and mixed urinary incontinence. Because there also is a possibility that cerebral deterioration in aging women causes gait and balance problems that increase the likelihood of urge incontinence, the authors advise against the use of anticholinergic agents in elderly women, as these drugs can impair cognitive function. Another take-home message from this French report is that we should counsel elderly patients about the importance of maintaining balance and mobility through exercise, physical therapy, or other strategies.
Andrew M. Kaunitz, MD

Urinary incontinence affects more than one-third of women aged 70 years or older. As the authors of this study point out, urinary incontinence is comparable to other chronic conditions, such as hypertension and diabetes mellitus, in its impact on quality of life, and is a common reason for institutionalization.

The risk of urinary incontinence increases with age. In elderly women, it is often mixed (ie, having both urge- and stress-related components) and associated with functional impairments, including reduced mobility. It is thought that the association between incontinence and functional impairment is related primarily to the urge component:

• Women with impaired mobility take longer to reach the toilet, increasing the risk of leakage when the urge to urinate is strong
• Women with urge incontinence may be more likely to limit their activities so that they are always near a toilet.

Cognitive impairment may also play a role, affecting motor skills and bladder control.

To better understand why advancing age is linked with urinary incontinence, Fritel and colleagues studied a population of 1,942 urban-dwelling French women aged 75 to 85 years (mean age, 79.3 years; mean body mass index, 25.9 kg/m²).

Details of the study
Investigators assessed the frequency and quantity of urine leaks, the impact of urinary incontinence on daily life, and the participants’ mobility and balance. Data on urinary incontinence were collected via a self-administered questionnaire (the International Consultation on Incontinence Questionnaire–Short Form). Motor-related physical function was assessed using standardized balance and gait tests.

Urinary incontinence was reported by 42% of participants. Of these women, 57% reported daily urine leakage, with mixed incontinence found to be more prevalent than urge incontinence, which was more prevalent than stress incontinence. Overall, women with urinary incontinence reported that its impact on daily life was mild. Among those with mixed or urge incontinence, limitations in mobility and balance were correlated significantly with the severity of incontinence.

What this evidence means for practice
These findings support earlier data suggesting that impaired mobility can promote urge and mixed urinary incontinence. Because there also is a possibility that cerebral deterioration in aging women causes gait and balance problems that increase the likelihood of urge incontinence, the authors advise against the use of anticholinergic agents in elderly women, as these drugs can impair cognitive function. Another take-home message from this French report is that we should counsel elderly patients about the importance of maintaining balance and mobility through exercise, physical therapy, or other strategies.
Andrew M. Kaunitz, MD

Most epidemiologic studies have found no elevated risk of breast cancer among women who undergo cosmetic breast augmentation. However, there is concern that implants, which are radio-opaque, may limit our ability to diagnose malignancies at an early stage using screening mammography.

In this study, investigators compared the stage distribution of breast cancers at diagnosis and documented breast cancer–specific survival among women with and without cosmetic breast implants. Twelve cross-sectional studies published after 2000 in the United States had evaluated stage distribution of breast cancer among women with and without cosmetic implants. As stated above, investigators found an elevated risk of nonlocalized breast cancer among women with implants in their meta-analysis of these studies (OR, 1.26), but this elevated risk did not achieve statistical significance. A second analysis of five studies found an elevated risk of breast cancer–specific mortality (OR, 1.38), compared with the general population (no implants), which did achieve significance.

MRI may be helpful—but is the expense justified?

More than 300,000 women underwent cosmetic breast augmentation in 2011 in the United States, an increase of roughly 800% since the early 1990s. The impaired visualization of breast tissue via mammography in these women ranges from 22% to 83%. In addition, the implants limit compression of the breasts during mammography, and capsular contraction further contributes to this problem.

Magnetic resonance imaging (MRI) may be helpful in screening women with cosmetic breast implants, but this technology is expensive, and evidence supporting its routine use in this population is limited.

Some mammographers use special techniques to better visualize the breast tissue of women with implants. These techniques include displacing the implant posteriorly and pulling the breast tissue in front of it. However, even with such strategies, as much as one-third of the breast tissue may be inadequately assessed.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
These findings underscore the importance of sharing the risks of nonlocalized breast malignancy and increased breast cancer mortality with patients who are considering cosmetic breast implants, as well as with women who have already undergone this common procedure. Future studies are needed to address relevant issues, including the role of 3-D (tomosynthesis) technology in screening women with breast implants and optimal screening intervals in this subgroup.
ANDREW M. KAUNITZ, MD

We want to hear from you. Tell us what you think.

Most epidemiologic studies have found no elevated risk of breast cancer among women who undergo cosmetic breast augmentation. However, there is concern that implants, which are radio-opaque, may limit our ability to diagnose malignancies at an early stage using screening mammography.

In this study, investigators compared the stage distribution of breast cancers at diagnosis and documented breast cancer–specific survival among women with and without cosmetic breast implants. Twelve cross-sectional studies published after 2000 in the United States had evaluated stage distribution of breast cancer among women with and without cosmetic implants. As stated above, investigators found an elevated risk of nonlocalized breast cancer among women with implants in their meta-analysis of these studies (OR, 1.26), but this elevated risk did not achieve statistical significance. A second analysis of five studies found an elevated risk of breast cancer–specific mortality (OR, 1.38), compared with the general population (no implants), which did achieve significance.

MRI may be helpful—but is the expense justified?

More than 300,000 women underwent cosmetic breast augmentation in 2011 in the United States, an increase of roughly 800% since the early 1990s. The impaired visualization of breast tissue via mammography in these women ranges from 22% to 83%. In addition, the implants limit compression of the breasts during mammography, and capsular contraction further contributes to this problem.

Magnetic resonance imaging (MRI) may be helpful in screening women with cosmetic breast implants, but this technology is expensive, and evidence supporting its routine use in this population is limited.

Some mammographers use special techniques to better visualize the breast tissue of women with implants. These techniques include displacing the implant posteriorly and pulling the breast tissue in front of it. However, even with such strategies, as much as one-third of the breast tissue may be inadequately assessed.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
These findings underscore the importance of sharing the risks of nonlocalized breast malignancy and increased breast cancer mortality with patients who are considering cosmetic breast implants, as well as with women who have already undergone this common procedure. Future studies are needed to address relevant issues, including the role of 3-D (tomosynthesis) technology in screening women with breast implants and optimal screening intervals in this subgroup.
ANDREW M. KAUNITZ, MD

We want to hear from you. Tell us what you think.

Most epidemiologic studies have found no elevated risk of breast cancer among women who undergo cosmetic breast augmentation. However, there is concern that implants, which are radio-opaque, may limit our ability to diagnose malignancies at an early stage using screening mammography.

In this study, investigators compared the stage distribution of breast cancers at diagnosis and documented breast cancer–specific survival among women with and without cosmetic breast implants. Twelve cross-sectional studies published after 2000 in the United States had evaluated stage distribution of breast cancer among women with and without cosmetic implants. As stated above, investigators found an elevated risk of nonlocalized breast cancer among women with implants in their meta-analysis of these studies (OR, 1.26), but this elevated risk did not achieve statistical significance. A second analysis of five studies found an elevated risk of breast cancer–specific mortality (OR, 1.38), compared with the general population (no implants), which did achieve significance.

MRI may be helpful—but is the expense justified?

More than 300,000 women underwent cosmetic breast augmentation in 2011 in the United States, an increase of roughly 800% since the early 1990s. The impaired visualization of breast tissue via mammography in these women ranges from 22% to 83%. In addition, the implants limit compression of the breasts during mammography, and capsular contraction further contributes to this problem.

Magnetic resonance imaging (MRI) may be helpful in screening women with cosmetic breast implants, but this technology is expensive, and evidence supporting its routine use in this population is limited.

Some mammographers use special techniques to better visualize the breast tissue of women with implants. These techniques include displacing the implant posteriorly and pulling the breast tissue in front of it. However, even with such strategies, as much as one-third of the breast tissue may be inadequately assessed.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
These findings underscore the importance of sharing the risks of nonlocalized breast malignancy and increased breast cancer mortality with patients who are considering cosmetic breast implants, as well as with women who have already undergone this common procedure. Future studies are needed to address relevant issues, including the role of 3-D (tomosynthesis) technology in screening women with breast implants and optimal screening intervals in this subgroup.
ANDREW M. KAUNITZ, MD

We want to hear from you. Tell us what you think.

Vaginal hysterectomy has a superior profile in terms of morbidity, safety, and cost, compared with other approaches to hysterectomy for benign disease. Despite this standing, vaginal hysterectomy is performed in a minority of cases. As the rates of other minimally invasive approaches—laparoscopic and robotic—have increased in the United States, the vaginal route has declined from 28% in 1998 to 20% in 2010.^1,2 In fact, a large majority (85%) of gynecologists in the United States perform fewer than five vaginal hysterectomies a year.³

The concept of same-day discharge after hysterectomy is not new. Previously published studies, including one from an author of this study,⁴ have shown that discharging patients 12 to 24 hours after laparoscopic or vaginal hysterectomy is feasible. However, outpatient hysterectomy generally has not been adopted to the same extent as outpatient cholecystectomy in the field of general surgery.

At a time of cost-containment and declining medical reimbursements, outpatient hysterectomy has the potential to affect the health-care economic landscape in a significant manner.

Details of the series
Zakaria and Levy describe a consecutive series of 1,071 women who underwent vaginal hysterectomy (performed by a single surgeon) according to a well-outlined outpatient protocol. Participants underwent preoperative counseling and evidence-based ­interventions (medications, hydration) before, during, and after surgery to preempt postoperative pain and nausea.

Median operative time was 34 minutes (range, 17–210 minutes), and median estimated blood loss was 45 mL (range,5–800 mL). Median uterine weight was 160 g (range, 25–1,380 g).

Following the protocol, same-day discharge (ie, within 12 hours) was accomplished in 96% of patients. A small number (41 women, or approximately 4%) required overnight hospitalization for pain, nausea, or the need to travel a significant distance to return to their home. Five patients required readmission or emergency room evaluation within the first postoperative month due to nausea and vomiting, abdominal pain, fever, pulmonary embolus, or vesicovaginal fistula.

Stengths and limitations
Besides demonstrating that patients can be discharged early, Zakaria and Levy also point out that even traditionally “difficult” vaginal cases—for example, nulliparous women (18% of cases), women with a history of cesarean delivery or pelvic surgery (20% of cases), and patients with uteri larger than 250 g (30% of cases)—can be accomplished vaginally. These cases all were performed using a vessel-sealing device over the 10 years of the series.

Single-surgeon and selection bias may limit the generalizability and conclusions of this study. Future investigations using a comparative cohort (with an inpatient arm) and employing validated measures to evaluate outcomes such as postoperative pain, total narcotic use, return to normal activity, and patient satisfaction, also would be helpful. In addition, it would be beneficial to determine whether the same protocol would be applicable to patients undergoing other hysterectomy approaches. 

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Most gynecologic practitioners continue to admit patients overnight following hysterectomy. This study demonstrates that same-day discharge is feasible and safe. It also highlights other routinely employed practices, such as the use of an indwelling catheter and liberal administration of intravenous narcotics postoperatively, that may adversely affect a patient’s recovery.
I strongly recommend that readers refer to this study and consider many of the techniques it describes to minimize postoperative pain and nausea in patients undergoing hysterectomy. Even when a patient is admitted overnight, techniques to minimize postoperative discomfort should be considered.

Vaginal hysterectomy has a superior profile in terms of morbidity, safety, and cost, compared with other approaches to hysterectomy for benign disease. Despite this standing, vaginal hysterectomy is performed in a minority of cases. As the rates of other minimally invasive approaches—laparoscopic and robotic—have increased in the United States, the vaginal route has declined from 28% in 1998 to 20% in 2010.^1,2 In fact, a large majority (85%) of gynecologists in the United States perform fewer than five vaginal hysterectomies a year.³

The concept of same-day discharge after hysterectomy is not new. Previously published studies, including one from an author of this study,⁴ have shown that discharging patients 12 to 24 hours after laparoscopic or vaginal hysterectomy is feasible. However, outpatient hysterectomy generally has not been adopted to the same extent as outpatient cholecystectomy in the field of general surgery.

At a time of cost-containment and declining medical reimbursements, outpatient hysterectomy has the potential to affect the health-care economic landscape in a significant manner.

Details of the series
Zakaria and Levy describe a consecutive series of 1,071 women who underwent vaginal hysterectomy (performed by a single surgeon) according to a well-outlined outpatient protocol. Participants underwent preoperative counseling and evidence-based ­interventions (medications, hydration) before, during, and after surgery to preempt postoperative pain and nausea.

Median operative time was 34 minutes (range, 17–210 minutes), and median estimated blood loss was 45 mL (range,5–800 mL). Median uterine weight was 160 g (range, 25–1,380 g).

Following the protocol, same-day discharge (ie, within 12 hours) was accomplished in 96% of patients. A small number (41 women, or approximately 4%) required overnight hospitalization for pain, nausea, or the need to travel a significant distance to return to their home. Five patients required readmission or emergency room evaluation within the first postoperative month due to nausea and vomiting, abdominal pain, fever, pulmonary embolus, or vesicovaginal fistula.

Stengths and limitations
Besides demonstrating that patients can be discharged early, Zakaria and Levy also point out that even traditionally “difficult” vaginal cases—for example, nulliparous women (18% of cases), women with a history of cesarean delivery or pelvic surgery (20% of cases), and patients with uteri larger than 250 g (30% of cases)—can be accomplished vaginally. These cases all were performed using a vessel-sealing device over the 10 years of the series.

Single-surgeon and selection bias may limit the generalizability and conclusions of this study. Future investigations using a comparative cohort (with an inpatient arm) and employing validated measures to evaluate outcomes such as postoperative pain, total narcotic use, return to normal activity, and patient satisfaction, also would be helpful. In addition, it would be beneficial to determine whether the same protocol would be applicable to patients undergoing other hysterectomy approaches. 

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Most gynecologic practitioners continue to admit patients overnight following hysterectomy. This study demonstrates that same-day discharge is feasible and safe. It also highlights other routinely employed practices, such as the use of an indwelling catheter and liberal administration of intravenous narcotics postoperatively, that may adversely affect a patient’s recovery.
I strongly recommend that readers refer to this study and consider many of the techniques it describes to minimize postoperative pain and nausea in patients undergoing hysterectomy. Even when a patient is admitted overnight, techniques to minimize postoperative discomfort should be considered.

Vaginal hysterectomy has a superior profile in terms of morbidity, safety, and cost, compared with other approaches to hysterectomy for benign disease. Despite this standing, vaginal hysterectomy is performed in a minority of cases. As the rates of other minimally invasive approaches—laparoscopic and robotic—have increased in the United States, the vaginal route has declined from 28% in 1998 to 20% in 2010.^1,2 In fact, a large majority (85%) of gynecologists in the United States perform fewer than five vaginal hysterectomies a year.³

The concept of same-day discharge after hysterectomy is not new. Previously published studies, including one from an author of this study,⁴ have shown that discharging patients 12 to 24 hours after laparoscopic or vaginal hysterectomy is feasible. However, outpatient hysterectomy generally has not been adopted to the same extent as outpatient cholecystectomy in the field of general surgery.

At a time of cost-containment and declining medical reimbursements, outpatient hysterectomy has the potential to affect the health-care economic landscape in a significant manner.

Details of the series
Zakaria and Levy describe a consecutive series of 1,071 women who underwent vaginal hysterectomy (performed by a single surgeon) according to a well-outlined outpatient protocol. Participants underwent preoperative counseling and evidence-based ­interventions (medications, hydration) before, during, and after surgery to preempt postoperative pain and nausea.

Median operative time was 34 minutes (range, 17–210 minutes), and median estimated blood loss was 45 mL (range,5–800 mL). Median uterine weight was 160 g (range, 25–1,380 g).

Following the protocol, same-day discharge (ie, within 12 hours) was accomplished in 96% of patients. A small number (41 women, or approximately 4%) required overnight hospitalization for pain, nausea, or the need to travel a significant distance to return to their home. Five patients required readmission or emergency room evaluation within the first postoperative month due to nausea and vomiting, abdominal pain, fever, pulmonary embolus, or vesicovaginal fistula.

Stengths and limitations
Besides demonstrating that patients can be discharged early, Zakaria and Levy also point out that even traditionally “difficult” vaginal cases—for example, nulliparous women (18% of cases), women with a history of cesarean delivery or pelvic surgery (20% of cases), and patients with uteri larger than 250 g (30% of cases)—can be accomplished vaginally. These cases all were performed using a vessel-sealing device over the 10 years of the series.

Single-surgeon and selection bias may limit the generalizability and conclusions of this study. Future investigations using a comparative cohort (with an inpatient arm) and employing validated measures to evaluate outcomes such as postoperative pain, total narcotic use, return to normal activity, and patient satisfaction, also would be helpful. In addition, it would be beneficial to determine whether the same protocol would be applicable to patients undergoing other hysterectomy approaches. 

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Most gynecologic practitioners continue to admit patients overnight following hysterectomy. This study demonstrates that same-day discharge is feasible and safe. It also highlights other routinely employed practices, such as the use of an indwelling catheter and liberal administration of intravenous narcotics postoperatively, that may adversely affect a patient’s recovery.
I strongly recommend that readers refer to this study and consider many of the techniques it describes to minimize postoperative pain and nausea in patients undergoing hysterectomy. Even when a patient is admitted overnight, techniques to minimize postoperative discomfort should be considered.

Inositol has generated increasing attention as a treatment for conditions related to pregnancy, including polycystic ovary syndrome¹ and neural tube defects.^2,3 In this study, pregnant women with a family history of type 2 diabetes were randomly allocated to:

• folic acid alone (400 µg daily)—placebo group
• folic acid plus myo-inositol (400 µg and 4 g daily, respectively)—treatment group.

The goal was to determine whether the addition of myo-inositol could prevent GDM and macrosomia. Because the study was conducted in Italy, GDM was diagnosed using recommendations from the International Association of Diabetes and Pregnancy Study Groups (IADPSG).⁴

Of the 197 women who completed the study, those given myo-inositol had a lower incidence of GDM than those given placebo: 6 of 99 women in the treatment group developed GDM, compared with 15 of 98 in the placebo group (P = .04). None of the women in the treatment group gave birth to a macrosomic infant (>4,000 g), compared with seven women in the placebo group (P = .007). However, other adverse outcomes, such as cesarean delivery, gestational hypertension, shoulder dystocia, preterm delivery, and fetal respiratory distress syndrome occurred at similar frequencies in the two groups.

RELATED ARTICLE Weight changes between pregnancies tied to risk of gestational diabetes mellitus (Web NEWS, June 2011)

How to improve outcomes in gestational diabetes—for mother and baby
E. Albert Reece, MD, PhD, MBA (March 2011)

Strengths and limitations of the study

Investigators conducted a prospective, randomized, placebo-controlled trial, one of the first moderately sized trials to examine the therapeutic effects of myo-inositol in pregnant women who had a family history of type 2 diabetes (in one or both parents). This study builds upon a previous report from the same investigators of the positive effects of myo-inositol in reducing insulin resistance in a smaller group of women (n = 69) with GDM.⁵

Another strength is that the investigators focused on a compound, inositol, readily found in foods, which suggests that women could derive benefits from a diet fortified with this supplement.

However, there are several concerns, also touched upon in a previous commentary about this study,⁶ which include:

• Only white women were included in the study. (As an ethnic group, white women have a lower risk of GDM.)
• All of the women enrolled in this trial had a prepregnancy body mass index within the normal range. Women who have a family history of type 2 diabetes who are also obese are a significant population to study.
• More work is needed to understand the mechanism of action of myo-inositol to help determine the optimal concentration to administer and the route of administration (ie, in pill form or as part of a diet plan).

Another important point: Investigators used IADPSG criteria to diagnose GDM; these criteria tend to identify significantly more cases of diabetes than the Carpenter and Coustan criteria, which are currently used in the United States.^7,8 Indeed, a National Institutes of Health expert panel recommended continuing use of the Carpenter and Coustan criteria to diagnose GDM in the United States until more data are collected to show correlation between changing the diagnostic threshold and improved fetal and maternal outcomes.⁹

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Current standards for identifying GDM include appropriate screening. Methods for prevention of GDM including dietary counseling and advice on an exercise program to reduce fetal macrosomia, but no interventions, to date, have effectively controlled GDM.

The concept of using a dietary supplement to prevent GDM is intriguing, and the results of this trial, coupled with a second recent report on the beneficial effects of myo-inositol to prevent GDM,10 are promising. However, the many concerns raised here—especially the use of IADPSG criteria—make it difficult to apply these findings to traditional diagnostic criteria for US practitioners. Follow-up, large-scale trials are needed to determine how effective this supplement is in preventing GDM and whether its effects translate into benefits for women at increased risk of developing diabetes. The routine use of myo-inositol in patients with a family history of type 2 diabetes should await further studies, including the aforementioned trials.

E. Albert Reece, MD, PhD, MBA

Inositol has generated increasing attention as a treatment for conditions related to pregnancy, including polycystic ovary syndrome¹ and neural tube defects.^2,3 In this study, pregnant women with a family history of type 2 diabetes were randomly allocated to:

• folic acid alone (400 µg daily)—placebo group
• folic acid plus myo-inositol (400 µg and 4 g daily, respectively)—treatment group.

The goal was to determine whether the addition of myo-inositol could prevent GDM and macrosomia. Because the study was conducted in Italy, GDM was diagnosed using recommendations from the International Association of Diabetes and Pregnancy Study Groups (IADPSG).⁴

Of the 197 women who completed the study, those given myo-inositol had a lower incidence of GDM than those given placebo: 6 of 99 women in the treatment group developed GDM, compared with 15 of 98 in the placebo group (P = .04). None of the women in the treatment group gave birth to a macrosomic infant (>4,000 g), compared with seven women in the placebo group (P = .007). However, other adverse outcomes, such as cesarean delivery, gestational hypertension, shoulder dystocia, preterm delivery, and fetal respiratory distress syndrome occurred at similar frequencies in the two groups.

RELATED ARTICLE Weight changes between pregnancies tied to risk of gestational diabetes mellitus (Web NEWS, June 2011)

How to improve outcomes in gestational diabetes—for mother and baby
E. Albert Reece, MD, PhD, MBA (March 2011)

Strengths and limitations of the study

Investigators conducted a prospective, randomized, placebo-controlled trial, one of the first moderately sized trials to examine the therapeutic effects of myo-inositol in pregnant women who had a family history of type 2 diabetes (in one or both parents). This study builds upon a previous report from the same investigators of the positive effects of myo-inositol in reducing insulin resistance in a smaller group of women (n = 69) with GDM.⁵

Another strength is that the investigators focused on a compound, inositol, readily found in foods, which suggests that women could derive benefits from a diet fortified with this supplement.

However, there are several concerns, also touched upon in a previous commentary about this study,⁶ which include:

• Only white women were included in the study. (As an ethnic group, white women have a lower risk of GDM.)
• All of the women enrolled in this trial had a prepregnancy body mass index within the normal range. Women who have a family history of type 2 diabetes who are also obese are a significant population to study.
• More work is needed to understand the mechanism of action of myo-inositol to help determine the optimal concentration to administer and the route of administration (ie, in pill form or as part of a diet plan).

Another important point: Investigators used IADPSG criteria to diagnose GDM; these criteria tend to identify significantly more cases of diabetes than the Carpenter and Coustan criteria, which are currently used in the United States.^7,8 Indeed, a National Institutes of Health expert panel recommended continuing use of the Carpenter and Coustan criteria to diagnose GDM in the United States until more data are collected to show correlation between changing the diagnostic threshold and improved fetal and maternal outcomes.⁹

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Current standards for identifying GDM include appropriate screening. Methods for prevention of GDM including dietary counseling and advice on an exercise program to reduce fetal macrosomia, but no interventions, to date, have effectively controlled GDM.

The concept of using a dietary supplement to prevent GDM is intriguing, and the results of this trial, coupled with a second recent report on the beneficial effects of myo-inositol to prevent GDM,10 are promising. However, the many concerns raised here—especially the use of IADPSG criteria—make it difficult to apply these findings to traditional diagnostic criteria for US practitioners. Follow-up, large-scale trials are needed to determine how effective this supplement is in preventing GDM and whether its effects translate into benefits for women at increased risk of developing diabetes. The routine use of myo-inositol in patients with a family history of type 2 diabetes should await further studies, including the aforementioned trials.

E. Albert Reece, MD, PhD, MBA

Inositol has generated increasing attention as a treatment for conditions related to pregnancy, including polycystic ovary syndrome¹ and neural tube defects.^2,3 In this study, pregnant women with a family history of type 2 diabetes were randomly allocated to:

• folic acid alone (400 µg daily)—placebo group
• folic acid plus myo-inositol (400 µg and 4 g daily, respectively)—treatment group.

The goal was to determine whether the addition of myo-inositol could prevent GDM and macrosomia. Because the study was conducted in Italy, GDM was diagnosed using recommendations from the International Association of Diabetes and Pregnancy Study Groups (IADPSG).⁴

Of the 197 women who completed the study, those given myo-inositol had a lower incidence of GDM than those given placebo: 6 of 99 women in the treatment group developed GDM, compared with 15 of 98 in the placebo group (P = .04). None of the women in the treatment group gave birth to a macrosomic infant (>4,000 g), compared with seven women in the placebo group (P = .007). However, other adverse outcomes, such as cesarean delivery, gestational hypertension, shoulder dystocia, preterm delivery, and fetal respiratory distress syndrome occurred at similar frequencies in the two groups.

RELATED ARTICLE Weight changes between pregnancies tied to risk of gestational diabetes mellitus (Web NEWS, June 2011)

How to improve outcomes in gestational diabetes—for mother and baby
E. Albert Reece, MD, PhD, MBA (March 2011)

Strengths and limitations of the study

Investigators conducted a prospective, randomized, placebo-controlled trial, one of the first moderately sized trials to examine the therapeutic effects of myo-inositol in pregnant women who had a family history of type 2 diabetes (in one or both parents). This study builds upon a previous report from the same investigators of the positive effects of myo-inositol in reducing insulin resistance in a smaller group of women (n = 69) with GDM.⁵

Another strength is that the investigators focused on a compound, inositol, readily found in foods, which suggests that women could derive benefits from a diet fortified with this supplement.

However, there are several concerns, also touched upon in a previous commentary about this study,⁶ which include:

• Only white women were included in the study. (As an ethnic group, white women have a lower risk of GDM.)
• All of the women enrolled in this trial had a prepregnancy body mass index within the normal range. Women who have a family history of type 2 diabetes who are also obese are a significant population to study.
• More work is needed to understand the mechanism of action of myo-inositol to help determine the optimal concentration to administer and the route of administration (ie, in pill form or as part of a diet plan).

Another important point: Investigators used IADPSG criteria to diagnose GDM; these criteria tend to identify significantly more cases of diabetes than the Carpenter and Coustan criteria, which are currently used in the United States.^7,8 Indeed, a National Institutes of Health expert panel recommended continuing use of the Carpenter and Coustan criteria to diagnose GDM in the United States until more data are collected to show correlation between changing the diagnostic threshold and improved fetal and maternal outcomes.⁹

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Current standards for identifying GDM include appropriate screening. Methods for prevention of GDM including dietary counseling and advice on an exercise program to reduce fetal macrosomia, but no interventions, to date, have effectively controlled GDM.

The concept of using a dietary supplement to prevent GDM is intriguing, and the results of this trial, coupled with a second recent report on the beneficial effects of myo-inositol to prevent GDM,10 are promising. However, the many concerns raised here—especially the use of IADPSG criteria—make it difficult to apply these findings to traditional diagnostic criteria for US practitioners. Follow-up, large-scale trials are needed to determine how effective this supplement is in preventing GDM and whether its effects translate into benefits for women at increased risk of developing diabetes. The routine use of myo-inositol in patients with a family history of type 2 diabetes should await further studies, including the aforementioned trials.

E. Albert Reece, MD, PhD, MBA

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

(Editor's note: Updated July 12, 2013.)

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

(Editor's note: Updated July 12, 2013.)

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

(Editor's note: Updated July 12, 2013.)

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.