On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”
Boosting Hospitalists’ Research Efforts
Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”
“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.
For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.
SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.
The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.
SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.
“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.
To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.
“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”
—Scott A. Flanders, MD, clinical associate professor, University of Michigan Health Systems, Ann Arbor
How Do Hospitalists Stack up?
In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”
The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.
The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.
The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.
Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.
As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.
The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.
Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.
Glycemic Control Issues
“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”
“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.
Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.
In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.
The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.
Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.
The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.
“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH