Pediatric hospitalists demonstrated their leadership and ownership of clinical hospital medicine on this year’s pediatric track at HM11.

Joel Tieder, MD, MPH, advocated for a balanced and risk-based approach to apparent life-threatening events (ALTEs). Although the differential for this observer-defined symptom remains broad, a link to perhaps the most worrisome outcome, sudden infant death syndrome (SIDS), has not been borne out in the medical literature. Testing seldom offers conclusive answers, Dr. Tieder said in his review.

Thus, a risk-based approach to guide work-up is prudent. Young age and a history of recurrent events are two factors that could signify risk for worrisome underlying pathology, to include infection and nonaccidental trauma. Dr. Tieder has worked with SHM to organize and lead an expert panel that hopes to release a white paper on this topic in the future.

John Pope, MD, Kris Rehm, MD, and Brian Alverson, MD, collectively presented an update on the top articles of the year relevant to pediatric HM.

Highlights included:

• The potential utility of the Pediatric Early Warning Score in identifying clinical deterioration;
• A reduction in symptoms in patients with irritable bowel syndrome given Lactobacillus GG;
• The positive impact of an antimicrobial stewardship program on vancomycin usage;
• The utility of the clinical examination in deciding whether a lumbar puncture is warranted to evaluate for bacterial meningitis in patients presenting with complex febrile seizures; and
• The adequacy of short-term IV antibiotic therapy in young infants with UTIs.

Dr. Alverson provided an update on the development of clinical practice guidelines for community-acquired pneumonia in children, highlighting his participation on a committee cosponsored by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Laboratory and radiographic data rarely clarify the diagnosis of clinical pneumonia and are not as useful in the outpatient setting but may be justified to look for complications in children who are hospitalized, he reported.

Other take-home points:

• Antimicrobial therapy in uncomplicated pneumonia should primarily target pneumococcus;
• Ampicillin and amoxicillin penetrate lung tissue well, and in high dosages can overcome most pneumococcal resistance; and
• Management of mycoplasma in children remains controversial and requires further investigation.
• The final guidelines are expected to be published sometime toward the end of the year.

Dr. Shen is pediatric editor of The Hospitalist.

Pediatric hospitalists demonstrated their leadership and ownership of clinical hospital medicine on this year’s pediatric track at HM11.

Joel Tieder, MD, MPH, advocated for a balanced and risk-based approach to apparent life-threatening events (ALTEs). Although the differential for this observer-defined symptom remains broad, a link to perhaps the most worrisome outcome, sudden infant death syndrome (SIDS), has not been borne out in the medical literature. Testing seldom offers conclusive answers, Dr. Tieder said in his review.

Thus, a risk-based approach to guide work-up is prudent. Young age and a history of recurrent events are two factors that could signify risk for worrisome underlying pathology, to include infection and nonaccidental trauma. Dr. Tieder has worked with SHM to organize and lead an expert panel that hopes to release a white paper on this topic in the future.

John Pope, MD, Kris Rehm, MD, and Brian Alverson, MD, collectively presented an update on the top articles of the year relevant to pediatric HM.

Highlights included:

• The potential utility of the Pediatric Early Warning Score in identifying clinical deterioration;
• A reduction in symptoms in patients with irritable bowel syndrome given Lactobacillus GG;
• The positive impact of an antimicrobial stewardship program on vancomycin usage;
• The utility of the clinical examination in deciding whether a lumbar puncture is warranted to evaluate for bacterial meningitis in patients presenting with complex febrile seizures; and
• The adequacy of short-term IV antibiotic therapy in young infants with UTIs.

Dr. Alverson provided an update on the development of clinical practice guidelines for community-acquired pneumonia in children, highlighting his participation on a committee cosponsored by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Laboratory and radiographic data rarely clarify the diagnosis of clinical pneumonia and are not as useful in the outpatient setting but may be justified to look for complications in children who are hospitalized, he reported.

Other take-home points:

• Antimicrobial therapy in uncomplicated pneumonia should primarily target pneumococcus;
• Ampicillin and amoxicillin penetrate lung tissue well, and in high dosages can overcome most pneumococcal resistance; and
• Management of mycoplasma in children remains controversial and requires further investigation.
• The final guidelines are expected to be published sometime toward the end of the year.

Dr. Shen is pediatric editor of The Hospitalist.

Pediatric hospitalists demonstrated their leadership and ownership of clinical hospital medicine on this year’s pediatric track at HM11.

Joel Tieder, MD, MPH, advocated for a balanced and risk-based approach to apparent life-threatening events (ALTEs). Although the differential for this observer-defined symptom remains broad, a link to perhaps the most worrisome outcome, sudden infant death syndrome (SIDS), has not been borne out in the medical literature. Testing seldom offers conclusive answers, Dr. Tieder said in his review.

Thus, a risk-based approach to guide work-up is prudent. Young age and a history of recurrent events are two factors that could signify risk for worrisome underlying pathology, to include infection and nonaccidental trauma. Dr. Tieder has worked with SHM to organize and lead an expert panel that hopes to release a white paper on this topic in the future.

John Pope, MD, Kris Rehm, MD, and Brian Alverson, MD, collectively presented an update on the top articles of the year relevant to pediatric HM.

Highlights included:

• The potential utility of the Pediatric Early Warning Score in identifying clinical deterioration;
• A reduction in symptoms in patients with irritable bowel syndrome given Lactobacillus GG;
• The positive impact of an antimicrobial stewardship program on vancomycin usage;
• The utility of the clinical examination in deciding whether a lumbar puncture is warranted to evaluate for bacterial meningitis in patients presenting with complex febrile seizures; and
• The adequacy of short-term IV antibiotic therapy in young infants with UTIs.

Dr. Alverson provided an update on the development of clinical practice guidelines for community-acquired pneumonia in children, highlighting his participation on a committee cosponsored by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Laboratory and radiographic data rarely clarify the diagnosis of clinical pneumonia and are not as useful in the outpatient setting but may be justified to look for complications in children who are hospitalized, he reported.

Other take-home points:

• Antimicrobial therapy in uncomplicated pneumonia should primarily target pneumococcus;
• Ampicillin and amoxicillin penetrate lung tissue well, and in high dosages can overcome most pneumococcal resistance; and
• Management of mycoplasma in children remains controversial and requires further investigation.
• The final guidelines are expected to be published sometime toward the end of the year.

Dr. Shen is pediatric editor of The Hospitalist.

GRAPEVINE, Texas—Femi Adewunmi, MD, MBA, SFHM, might land a new job as a multisite medical director because of it. Amaka Nweke, MD, might have gained an idea for a new committee for her hospital from it. And Randa Perkins, MD, is going to lead one long brown-bag lunch thanks to it.

Everyone gets something different out of SHM’s annual meeting, a four-day bazaar of CME, plenary sessions, and breakout sessions akin to one-hour crash courses that follow clinical, academic, practice management, pediatric, and quality tracks.

The Hospitalist sat down with three attendees to break down what each took home from HM11.

New Year, New Job?

A veteran of multiple annual meetings, Dr. Adewunmi usually splits his time between breakout sessions and networking. But this year, the former medical director of the hospitalist service at Johnston Medical Center in Smithfield, N.C., says he’s looking to step up from a single-site leadership position to a regional head. So the mission was more about networking than note-taking.

“It’s been invaluable for me at this point,” Dr. Adewunmi says, “as I navigate and decide what the next steps should be in terms of my career progression.”

Of course, that progression meant using his time-management skills to hold discussions with potential employers.

“I was in and out,” he says, noting he’s been doing locum tenens work for several months as he weighs his next move. “Sometimes, if you want to have the time to meet one-on-one [at the exhibitor hall]without the crowd and the distractions, it’s probably easier and better to go in between sessions.”

Dr. Adewunmi, a newly seated member of Team Hospitalist, says he met with eight to 10 of the largest HM firms during the meeting. He leveraged contacts he’s built over the years, and also used relationships with SHM staff to make introductions. He thinks employers appreciate the annual meeting for the same reason.

“It’s one spot where rather than trying to fly in 10 or 20 candidates every month or every few weeks, you can just come in one spot and interview several people … or put your feelers out,” he says. “It works both ways.”

Dr. Adewunmi can’t be sure his networking will be successful. He plans to keep working locums with one potential employer so both sides can get to know each other. But even if nothing pans out, between the clinical sessions he attended and the relationships he either built or strengthened, he says he’s glad he came again to the annual meeting.

“This, for me, has always been the best resource in terms of place you could come to one stop and get a little bit of everything,” he adds. “It’s like a buffet.”

Meet and Greet, Over and Over

Dr. Nweke, assistant site director for Hospitalists Management Group at Kenosha Medical Center in Wisconsin, wasn’t going to let her first meeting overwhelm her. She laid out her agenda early, planning to attend as many practice management and leadership classes as she could. When she arrived, she sat through talks including “Understanding Your Hospital’s Key Financial Drivers,” “Hiding in Plain Sight,” and “Introduction to QI Methodology.”

But it was a session on basic tips to improve patient-satisfaction scores that gave her the most feedback.

“There are a lot of things you kind of instinctively know just as a human being as opposed to being a physician,” Dr. Nweke says. “It’s only polite that you shake the hand of the person you’re meeting and you smile at them, as opposed to being a grouch. But it’s interesting to hear what questions are asked in the patient surveys. While I was there, I actually sat thinking from a patient’s perspective: ‘What would I be looking for in my hospital?’ ”

Dr. Nweke admittedly felt a bit frustrated with some sessions, as she’d hoped to extract more advanced tips. However, she had no complaints about the networking opportunities. Everywhere she turned, she says, she had the chance to discuss ideas with new faces.

“I’ve randomly met people, introduced myself to people, and talked about different challenges,” she says. “For someone like me, it’s really very important because I’m at the bottom of the totem pole, so to speak, as far as leadership.”

One bit of practical advice Dr. Nweke learned from meeting someone was the idea of a medical records committee. One of her new contacts chairs such a committee, which prompted Dr. Nweke to check in with her hospital while the annual meeting was happening. Turns out, her hospital doesn’t have a similar committee. Yet.

“Maybe this might be something I could throw out there and say, ‘How about we do this or that?’ ” Dr. Nweke adds, “whatever it might be, little things that I could do to improve and add some value and worth to my program, and our relationship with the hospital.”

A Kid in a Candy Store

If Dr. Perkins ever becomes president of the society, HM11 will be why. A self-proclaimed lame-duck chief resident at Tallahassee Memorial’s Family Medicine Residency Program in Florida, she’d already signed her first contract as a hospitalist and starts the job in August. Yet she didn’t know about SHM or the annual meeting until shortly before it started, when a community physician mentioned it to her.

So she booked a room at a nearby hotel (the 1,551-room Gaylord Texan Resort and Convention Center having filled up early) and spent the last of her CME money on HM11. She had trouble picking out any specific tips she wanted to take home to her new practice, Tallahassee Memorial HealthCare Hospitalists Group, as she had so many.

She sat in a recruitment session just to have things to tell her new boss. She took feverish notes during a presentation on best practices in the ICU because she’ll be spending a lot of time there. And during a meet-and-greet pairing residents with potential mentors, she befriended Daniel Dressler, MD, MSc, SFHM, an SHM board member, HM11’s course director, and academic hospitalist heavyweight at Emory University Hospital in Atlanta.

“It’s kind of like when you start any adventure, you don’t have everything laid out in a guidebook,” Dr. Perkins says. “You just kind of have to put your feet out there and start moving and hope to God that things fall into your lap sometimes. This conference kind of did. This is kind of my guidebook, this is my compass, this is what I can look to when I’m trying to figure out how to make my own path in the specialty.”

Dr. Perkins adds that the fraternal feel of HM11 makes her feel like she chose the right specialty. Given all of the research talk, she might even start pushing her 12-member hospitalist group to begin more projects that could “help our community.”

“All the educational opportunities that were at the conference pulled me into it and then, all of a sudden, all these resources are laid out in front of me,” she adds. “I’m literally a kid in a candy store with access to data and information and guides. It’s great.” TH

GRAPEVINE, Texas—Femi Adewunmi, MD, MBA, SFHM, might land a new job as a multisite medical director because of it. Amaka Nweke, MD, might have gained an idea for a new committee for her hospital from it. And Randa Perkins, MD, is going to lead one long brown-bag lunch thanks to it.

Everyone gets something different out of SHM’s annual meeting, a four-day bazaar of CME, plenary sessions, and breakout sessions akin to one-hour crash courses that follow clinical, academic, practice management, pediatric, and quality tracks.

The Hospitalist sat down with three attendees to break down what each took home from HM11.

New Year, New Job?

A veteran of multiple annual meetings, Dr. Adewunmi usually splits his time between breakout sessions and networking. But this year, the former medical director of the hospitalist service at Johnston Medical Center in Smithfield, N.C., says he’s looking to step up from a single-site leadership position to a regional head. So the mission was more about networking than note-taking.

“It’s been invaluable for me at this point,” Dr. Adewunmi says, “as I navigate and decide what the next steps should be in terms of my career progression.”

Of course, that progression meant using his time-management skills to hold discussions with potential employers.

“I was in and out,” he says, noting he’s been doing locum tenens work for several months as he weighs his next move. “Sometimes, if you want to have the time to meet one-on-one [at the exhibitor hall]without the crowd and the distractions, it’s probably easier and better to go in between sessions.”

Dr. Adewunmi, a newly seated member of Team Hospitalist, says he met with eight to 10 of the largest HM firms during the meeting. He leveraged contacts he’s built over the years, and also used relationships with SHM staff to make introductions. He thinks employers appreciate the annual meeting for the same reason.

“It’s one spot where rather than trying to fly in 10 or 20 candidates every month or every few weeks, you can just come in one spot and interview several people … or put your feelers out,” he says. “It works both ways.”

Dr. Adewunmi can’t be sure his networking will be successful. He plans to keep working locums with one potential employer so both sides can get to know each other. But even if nothing pans out, between the clinical sessions he attended and the relationships he either built or strengthened, he says he’s glad he came again to the annual meeting.

“This, for me, has always been the best resource in terms of place you could come to one stop and get a little bit of everything,” he adds. “It’s like a buffet.”

Meet and Greet, Over and Over

Dr. Nweke, assistant site director for Hospitalists Management Group at Kenosha Medical Center in Wisconsin, wasn’t going to let her first meeting overwhelm her. She laid out her agenda early, planning to attend as many practice management and leadership classes as she could. When she arrived, she sat through talks including “Understanding Your Hospital’s Key Financial Drivers,” “Hiding in Plain Sight,” and “Introduction to QI Methodology.”

But it was a session on basic tips to improve patient-satisfaction scores that gave her the most feedback.

“There are a lot of things you kind of instinctively know just as a human being as opposed to being a physician,” Dr. Nweke says. “It’s only polite that you shake the hand of the person you’re meeting and you smile at them, as opposed to being a grouch. But it’s interesting to hear what questions are asked in the patient surveys. While I was there, I actually sat thinking from a patient’s perspective: ‘What would I be looking for in my hospital?’ ”

Dr. Nweke admittedly felt a bit frustrated with some sessions, as she’d hoped to extract more advanced tips. However, she had no complaints about the networking opportunities. Everywhere she turned, she says, she had the chance to discuss ideas with new faces.

“I’ve randomly met people, introduced myself to people, and talked about different challenges,” she says. “For someone like me, it’s really very important because I’m at the bottom of the totem pole, so to speak, as far as leadership.”

One bit of practical advice Dr. Nweke learned from meeting someone was the idea of a medical records committee. One of her new contacts chairs such a committee, which prompted Dr. Nweke to check in with her hospital while the annual meeting was happening. Turns out, her hospital doesn’t have a similar committee. Yet.

“Maybe this might be something I could throw out there and say, ‘How about we do this or that?’ ” Dr. Nweke adds, “whatever it might be, little things that I could do to improve and add some value and worth to my program, and our relationship with the hospital.”

A Kid in a Candy Store

If Dr. Perkins ever becomes president of the society, HM11 will be why. A self-proclaimed lame-duck chief resident at Tallahassee Memorial’s Family Medicine Residency Program in Florida, she’d already signed her first contract as a hospitalist and starts the job in August. Yet she didn’t know about SHM or the annual meeting until shortly before it started, when a community physician mentioned it to her.

So she booked a room at a nearby hotel (the 1,551-room Gaylord Texan Resort and Convention Center having filled up early) and spent the last of her CME money on HM11. She had trouble picking out any specific tips she wanted to take home to her new practice, Tallahassee Memorial HealthCare Hospitalists Group, as she had so many.

She sat in a recruitment session just to have things to tell her new boss. She took feverish notes during a presentation on best practices in the ICU because she’ll be spending a lot of time there. And during a meet-and-greet pairing residents with potential mentors, she befriended Daniel Dressler, MD, MSc, SFHM, an SHM board member, HM11’s course director, and academic hospitalist heavyweight at Emory University Hospital in Atlanta.

“It’s kind of like when you start any adventure, you don’t have everything laid out in a guidebook,” Dr. Perkins says. “You just kind of have to put your feet out there and start moving and hope to God that things fall into your lap sometimes. This conference kind of did. This is kind of my guidebook, this is my compass, this is what I can look to when I’m trying to figure out how to make my own path in the specialty.”

Dr. Perkins adds that the fraternal feel of HM11 makes her feel like she chose the right specialty. Given all of the research talk, she might even start pushing her 12-member hospitalist group to begin more projects that could “help our community.”

“All the educational opportunities that were at the conference pulled me into it and then, all of a sudden, all these resources are laid out in front of me,” she adds. “I’m literally a kid in a candy store with access to data and information and guides. It’s great.” TH

GRAPEVINE, Texas—Femi Adewunmi, MD, MBA, SFHM, might land a new job as a multisite medical director because of it. Amaka Nweke, MD, might have gained an idea for a new committee for her hospital from it. And Randa Perkins, MD, is going to lead one long brown-bag lunch thanks to it.

Everyone gets something different out of SHM’s annual meeting, a four-day bazaar of CME, plenary sessions, and breakout sessions akin to one-hour crash courses that follow clinical, academic, practice management, pediatric, and quality tracks.

The Hospitalist sat down with three attendees to break down what each took home from HM11.

New Year, New Job?

A veteran of multiple annual meetings, Dr. Adewunmi usually splits his time between breakout sessions and networking. But this year, the former medical director of the hospitalist service at Johnston Medical Center in Smithfield, N.C., says he’s looking to step up from a single-site leadership position to a regional head. So the mission was more about networking than note-taking.

“It’s been invaluable for me at this point,” Dr. Adewunmi says, “as I navigate and decide what the next steps should be in terms of my career progression.”

Of course, that progression meant using his time-management skills to hold discussions with potential employers.

“I was in and out,” he says, noting he’s been doing locum tenens work for several months as he weighs his next move. “Sometimes, if you want to have the time to meet one-on-one [at the exhibitor hall]without the crowd and the distractions, it’s probably easier and better to go in between sessions.”

Dr. Adewunmi, a newly seated member of Team Hospitalist, says he met with eight to 10 of the largest HM firms during the meeting. He leveraged contacts he’s built over the years, and also used relationships with SHM staff to make introductions. He thinks employers appreciate the annual meeting for the same reason.

“It’s one spot where rather than trying to fly in 10 or 20 candidates every month or every few weeks, you can just come in one spot and interview several people … or put your feelers out,” he says. “It works both ways.”

Dr. Adewunmi can’t be sure his networking will be successful. He plans to keep working locums with one potential employer so both sides can get to know each other. But even if nothing pans out, between the clinical sessions he attended and the relationships he either built or strengthened, he says he’s glad he came again to the annual meeting.

“This, for me, has always been the best resource in terms of place you could come to one stop and get a little bit of everything,” he adds. “It’s like a buffet.”

Meet and Greet, Over and Over

Dr. Nweke, assistant site director for Hospitalists Management Group at Kenosha Medical Center in Wisconsin, wasn’t going to let her first meeting overwhelm her. She laid out her agenda early, planning to attend as many practice management and leadership classes as she could. When she arrived, she sat through talks including “Understanding Your Hospital’s Key Financial Drivers,” “Hiding in Plain Sight,” and “Introduction to QI Methodology.”

But it was a session on basic tips to improve patient-satisfaction scores that gave her the most feedback.

“There are a lot of things you kind of instinctively know just as a human being as opposed to being a physician,” Dr. Nweke says. “It’s only polite that you shake the hand of the person you’re meeting and you smile at them, as opposed to being a grouch. But it’s interesting to hear what questions are asked in the patient surveys. While I was there, I actually sat thinking from a patient’s perspective: ‘What would I be looking for in my hospital?’ ”

Dr. Nweke admittedly felt a bit frustrated with some sessions, as she’d hoped to extract more advanced tips. However, she had no complaints about the networking opportunities. Everywhere she turned, she says, she had the chance to discuss ideas with new faces.

“I’ve randomly met people, introduced myself to people, and talked about different challenges,” she says. “For someone like me, it’s really very important because I’m at the bottom of the totem pole, so to speak, as far as leadership.”

One bit of practical advice Dr. Nweke learned from meeting someone was the idea of a medical records committee. One of her new contacts chairs such a committee, which prompted Dr. Nweke to check in with her hospital while the annual meeting was happening. Turns out, her hospital doesn’t have a similar committee. Yet.

“Maybe this might be something I could throw out there and say, ‘How about we do this or that?’ ” Dr. Nweke adds, “whatever it might be, little things that I could do to improve and add some value and worth to my program, and our relationship with the hospital.”

A Kid in a Candy Store

If Dr. Perkins ever becomes president of the society, HM11 will be why. A self-proclaimed lame-duck chief resident at Tallahassee Memorial’s Family Medicine Residency Program in Florida, she’d already signed her first contract as a hospitalist and starts the job in August. Yet she didn’t know about SHM or the annual meeting until shortly before it started, when a community physician mentioned it to her.

So she booked a room at a nearby hotel (the 1,551-room Gaylord Texan Resort and Convention Center having filled up early) and spent the last of her CME money on HM11. She had trouble picking out any specific tips she wanted to take home to her new practice, Tallahassee Memorial HealthCare Hospitalists Group, as she had so many.

She sat in a recruitment session just to have things to tell her new boss. She took feverish notes during a presentation on best practices in the ICU because she’ll be spending a lot of time there. And during a meet-and-greet pairing residents with potential mentors, she befriended Daniel Dressler, MD, MSc, SFHM, an SHM board member, HM11’s course director, and academic hospitalist heavyweight at Emory University Hospital in Atlanta.

“It’s kind of like when you start any adventure, you don’t have everything laid out in a guidebook,” Dr. Perkins says. “You just kind of have to put your feet out there and start moving and hope to God that things fall into your lap sometimes. This conference kind of did. This is kind of my guidebook, this is my compass, this is what I can look to when I’m trying to figure out how to make my own path in the specialty.”

Dr. Perkins adds that the fraternal feel of HM11 makes her feel like she chose the right specialty. Given all of the research talk, she might even start pushing her 12-member hospitalist group to begin more projects that could “help our community.”

“All the educational opportunities that were at the conference pulled me into it and then, all of a sudden, all these resources are laid out in front of me,” she adds. “I’m literally a kid in a candy store with access to data and information and guides. It’s great.” TH

click for large version

Case

A 66-year-old Caucasian female with moderate chronic obstructive pulmonary disease (COPD) (FEV1 55% predicted), obesity, hypertension, and Type 2 diabetes mellitus on insulin therapy presents to the ED with four days of increased cough productive of yellow sputum and progressive shortness of breath. Her physical exam is notable for an oxygen saturation of 87% on room air, along with diffuse expiratory wheezing with use of accessory muscles; her chest X-ray is unchanged from previous. The patient is given oxygen, nebulized bronchodilators, and one dose of IV methylprednisolone. Her symptoms do not improve significantly, and she is admitted for further management. What regimen of corticosteroids is most appropriate to treat her acute exacerbation of COPD?

Overview

COPD is the fourth-leading cause of death in the United States and continues to increase in prevalence.1 Acute exacerbations of COPD (AECOPD) contribute significantly to this high mortality rate, which approaches 40% at one year in those patients requiring mechanical support.¹ An exacerbation of COPD has been defined as an acute change in a patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.² Exacerbations commonly occur in COPD patients and often necessitate hospital admission. In fact, COPD consistently is one of the 10 most common reasons for hospitalization, with billions of dollars in associated healthcare costs.³

The goals for inpatient management of AECOPD are to provide acute symptom relief and to minimize the potential for subsequent exacerbations. These are accomplished via a multifaceted approach, including the use of bronchodilators, antibiotics, supplemental oxygen, noninvasive positive pressure ventilation in certain circumstances, and systemic corticosteroids.

The administration of systemic steroids in AECOPD has been prevalent for several decades, with initial studies showing positive effects on lung function, specifically FEV1.⁴ Studies have demonstrated the benefit of steroids in prolonging the time to subsequent exacerbation, reducing the rate of treatment failure, and reducing length of stay (LOS).⁵ Corticosteroids have since become an essential component of the standard of care in AECOPD management.

Despite consensus that systemic steroids should be used in COPD exacerbations, a great deal of controversy still surrounds the optimal steroid regimen.⁶ Steroid use is not without risk, as steroids can lead to adverse outcomes in medically complex hospitalized patients (see Table 1, below). Current guidelines provide limited guidance as to the optimal route of administration, dosing regimen, or length of therapy; clinical practice varies widely.

Review of the Data

Administration route: intravenous (IV) vs. oral. The use of steroids in AECOPD began with such IV formulations as methylprednisolone, and this became the typical method of treating hospitalized patients. This practice was validated in a multicenter Veterans Affairs trial, which demonstrated decreased risk of treatment failure (defined as all-cause mortality, need for intubation, readmission for COPD, or intensification of pharmacologic therapy) for patients randomized to receive an IV-to-oral steroid regimen compared with those randomized to placebo.5 Patients receiving steroids also had shorter LOS and improvements in FEV1 after the first day of treatment. Subsequent randomized controlled trials in patients with AECOPD demonstrated the benefit of oral regimens compared with placebo with regard to FEV1, LOS, and risk of treatment failure.^6,7,8

Similarities in the bioavailability of oral and IV steroids have been known for a long time.⁹ Comparisons in efficacy initially were completed in the management of acute asthma exacerbations, with increasing evidence, including a meta-analysis, demonstrating no difference in improvement in pulmonary function and in preventing relapse of exacerbations for oral compared with IV steroids.¹⁰ However, only recently have oral and IV steroids been compared in the treatment of AECOPD. De Jong et al randomized more than 200 patients hospitalized for AECOPD to 60 mg of either IV or oral prednisolone for five days, followed by a week of an oral taper.¹¹ There were no significant differences in treatment failure between the IV and oral groups (62% vs. 56%, respectively, at 90 days; one-sided lower bound of the 95% confidence interval [CI], −5.8%).

click for large version

A large observational study by Lindenauer et al, including nearly 80,000 AECOPD patients admitted at more than 400 hospitals, added further support to the idea that oral and IV steroids were comparable in efficacy.¹² In this study, multivariate analysis found no difference in treatment failure between oral and IV groups (odds ratio [OR] 0.93; 95% CI, 0.84-1.02). The authors also found, however, that current clinical practice still overwhelmingly favors intravenous steroids, with 92% of study patients initially being administered IV steroids.¹²

Based on the evidence from de Jong and Lindenauer, it appears that there is no significant benefit to the use of IV over oral steroids. Additionally, there is evidence for oral administration being associated with beneficial effects on cost and hospital LOS.¹² Oral steroids, therefore, are the preferred route of administration to treat a hospitalized patient with AECOPD, unless the patient is unable to tolerate oral medications. Current guidelines support the practice of giving oral steroids as first-line treatment for AECOPD (see Table 2, above).

High dose vs. low dose. Another important clinical issue concerns the dosing of steroids. The randomized trials examining the use of corticosteroids in AECOPD vary widely in the dosages studied. Further, the majority of these trials have compared steroids to placebo, rather than comparing different dosage regimens. The agents studied have included prednisone, prednisolone, methylprednisolone, and hydrocortisone, or combinations thereof. In order to compare regimens of these different drugs, steroid doses often are converted into prednisone equivalents (see Table 3, below). Though no guidelines define “high dose” and “low dose,” some studies have designated doses of >80 mg prednisone equivalents daily as high-dose and prednisone equivalents of ≤80 mg daily as low-dose.^13,14

click for large version

Starting doses of systemic corticosteroids in the treatment of AECOPD in clinical studies range from prednisone equivalents of 30 mg daily to 625 mg on the first day of treatment.^5,8 No randomized studies of high- versus low-dose steroid regimens have been conducted. One retrospective chart review of 145 AECOPD admissions evaluated outcomes among patients who were given higher (mean daily dose >80 mg prednisone equivalent) and lower (mean daily dose of ≤80 mg prednisone) doses.¹⁴ The authors found that patients who received higher doses of steroids had significantly longer LOS compared with those who received lower doses, especially among the subset of patients who were admitted to the floor rather than the ICU, though this analysis did not adjust for severity of illness. In this study, the most striking finding noted by the authors was the wide variability in the steroid doses prescribed for the inpatient treatment of AECOPD.

More recently, the study by Lindenauer et al examined outcomes between patients treated with high-dose IV steroids (equivalent of 120 mg-800 mg of prednisone on the first or second day of treatment) compared to low-dose oral steroids (prednisone equivalents of 20 mg-80 mg per day).¹² The authors found no differences between the two groups regarding the rate of treatment failure, defined by initiation of mechanical ventilation after the second hospital day, in-hospital mortality, or readmission for COPD within 30 days of discharge. After multivariate adjustment, including the propensity for oral treatment, the low-dose oral therapy group was found to have lower risk of treatment failure, shorter LOS, and lower total hospital cost.

Despite the heterogeneity of the published data and the lack of randomized trials, the existing evidence suggests that low-dose prednisone (or equivalent) is similar in efficacy to higher doses and generally is associated with shorter hospital stays. Recognizing these benefits, guidelines do favor initiating treatment with low-dose steroids in patients admitted with AECOPD. The most recent publications from the American Thoracic Society/European Respiratory Society Task Force (ATS/ERS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Clinical Guidelines Centre in the United Kingdom, and the Canadian Thoracic Society all recommend equivalent dosing of prednisone in patients admitted with AECOPD who are able to tolerate oral intake (see Table 2).^1,2,15,16

Duration. As with the dosing of systemic corticosteroids in AECOPD, the optimal duration of treatment is not well-established. National and international consensus panels vary in their recommendations, as outlined in Table 2. This may be related to the variability in length of treatment found in the literature.

Treatment durations ranging from one day to eight weeks have been studied in inpatients with AECOPD. The landmark randomized controlled trial by Niewoehner and colleagues compared two-week and eight-week courses of systemic corticosteroids and found no difference in the rates of treatment failure, which included death, need for mechanical ventilation, readmission for COPD, and intensification of pharmacologic therapy.⁵ Based on these results, many experts have concluded that there is no benefit to steroid courses lasting beyond two weeks.

Although improvements in outcomes have been demonstrated with corticosteroid regimens as short as three days compared with placebo, most of the randomized controlled trials have included courses of seven to 14 days.⁴ Given the risks of adverse events (e.g. hyperglycemia) that are associated with systemic administration of steroids, the shortest effective duration should be considered.

click for large version

In both clinical practice and clinical studies, steroid regimens often include a taper. A study by Vondracek and Hemstreet found that 79% of hospital discharges for AECOPD included a tapered corticosteroid regimen.¹⁴ From a physiologic standpoint, durations of corticosteroid treatment approximately three weeks or less, regardless of dosage, should not lead to adrenal suppression.¹⁷ There also is no evidence to suggest that abrupt discontinuation of steroids leads to clinical worsening of disease, and complicated steroid tapers are a potential source of medication errors after hospital discharge.¹⁸ Furthermore, the clinical guidelines do not address the tapering of corticosteroids. Therefore, there is a lack of evidence advocating for or against the use of tapered steroid regimens in AECOPD.

Back to the Case

In addition to standard treatment modalities for AECOPD, our patient was administered oral prednisone 40 mg daily. She experienced steroid-induced hyperglycemia, which was corrected with adjustment of her insulin regimen. The patient’s pulmonary symptoms improved within 72 hours, and she was discharged home on hospital day four to complete a seven-day steroid course. At hospital discharge, she was administered influenza and pneumococcal vaccinations, and she was instructed to resume her usual insulin dosing once she finished her prednisone course.

Overview

In the management of AECOPD, there remains a lack of consensus in defining the ideal steroid regimen. Based on current literature, the use of low-dose oral corticosteroids, such as prednisone 40 mg daily, for a seven- to 14-day course is recommended. TH

Dr. Cunningham is an assistant professor of internal medicine and academic hospitalist in the section of hospital medicine at Vanderbilt University School of Medicine in Nashville, Tenn. Dr. LaBrin is an assistant professor of internal medicine and pediatrics and academic hospitalist at Vanderbilt University School of Medicine.

References

1. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Global Initiative for Chronic Obstructive Lung Disease website. Available at: www.goldcopd.org/GuidelineItem.asp?intId=989. Accessed Feb. 21, 2011.
2. Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.
3. Morbidity and mortality: 2009 chart book on cardiovascular, lung, and blood diseases. National Institutes of Health’s National Heart, Lung, and Blood Institute website. Available at: www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed Feb. 24, 2011.
4. Albert RK, Martin TR, Lewis SW. Controlled trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency. Ann Intern Med. 1980;92(6):753-758.
5. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941-1947.
6. Thompson WH, Nielson C, Carvalho P, Charan NB, Crowley JJ. Controlled trial of oral prednisone in outpatients with acute COPD exacerbation. Am J Respir Crit Care Med. 1996;154:407-412.
7. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161:1608-1613.
8. Davies L, Angus RM, Calverley PM. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet. 1999;354(9177):456-460.
9. Al-Habet S, Rogers HJ. Pharmacokinetics of intravenous and oral prednisolone. Br J Clin Pharmacol. 1980;10(5):503-508.
10. Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. 1992;10:301-310.
11. De Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: A randomized, controlled, double-blind study. Chest. 2007;132(6):1741-1747.
12. Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359-2367.
13. Manser R, Reid D, Abramsom MJ. Corticosteroids for acute severe asthma in hospitalized patients. Cochrane Database Syst Rev. 2000;(2):CD001740.
14. Vondracek SF, Hemstreet BA. Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2006;63:645-652.
15. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Institute for Health and Clinical Excellence website. Available at: guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed Feb. 21, 2011.
16. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease—2007 update. Can Respir J. 2007;14 Suppl B:5B-32B.
17. Webb J, Clark TJ. Recovery of plasma corticotrophin and cortisol levels after three-week course of prednisolone. Thorax. 1981;36:22-24.
18. O’Driscoll BR, Kalra S, Wilson M, Pickering CA, Carroll KB, Woodcock AA. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993; 341:324-7.

click for large version

Case

A 66-year-old Caucasian female with moderate chronic obstructive pulmonary disease (COPD) (FEV1 55% predicted), obesity, hypertension, and Type 2 diabetes mellitus on insulin therapy presents to the ED with four days of increased cough productive of yellow sputum and progressive shortness of breath. Her physical exam is notable for an oxygen saturation of 87% on room air, along with diffuse expiratory wheezing with use of accessory muscles; her chest X-ray is unchanged from previous. The patient is given oxygen, nebulized bronchodilators, and one dose of IV methylprednisolone. Her symptoms do not improve significantly, and she is admitted for further management. What regimen of corticosteroids is most appropriate to treat her acute exacerbation of COPD?

Overview

COPD is the fourth-leading cause of death in the United States and continues to increase in prevalence.1 Acute exacerbations of COPD (AECOPD) contribute significantly to this high mortality rate, which approaches 40% at one year in those patients requiring mechanical support.¹ An exacerbation of COPD has been defined as an acute change in a patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.² Exacerbations commonly occur in COPD patients and often necessitate hospital admission. In fact, COPD consistently is one of the 10 most common reasons for hospitalization, with billions of dollars in associated healthcare costs.³

The goals for inpatient management of AECOPD are to provide acute symptom relief and to minimize the potential for subsequent exacerbations. These are accomplished via a multifaceted approach, including the use of bronchodilators, antibiotics, supplemental oxygen, noninvasive positive pressure ventilation in certain circumstances, and systemic corticosteroids.

The administration of systemic steroids in AECOPD has been prevalent for several decades, with initial studies showing positive effects on lung function, specifically FEV1.⁴ Studies have demonstrated the benefit of steroids in prolonging the time to subsequent exacerbation, reducing the rate of treatment failure, and reducing length of stay (LOS).⁵ Corticosteroids have since become an essential component of the standard of care in AECOPD management.

Despite consensus that systemic steroids should be used in COPD exacerbations, a great deal of controversy still surrounds the optimal steroid regimen.⁶ Steroid use is not without risk, as steroids can lead to adverse outcomes in medically complex hospitalized patients (see Table 1, below). Current guidelines provide limited guidance as to the optimal route of administration, dosing regimen, or length of therapy; clinical practice varies widely.

Review of the Data

Administration route: intravenous (IV) vs. oral. The use of steroids in AECOPD began with such IV formulations as methylprednisolone, and this became the typical method of treating hospitalized patients. This practice was validated in a multicenter Veterans Affairs trial, which demonstrated decreased risk of treatment failure (defined as all-cause mortality, need for intubation, readmission for COPD, or intensification of pharmacologic therapy) for patients randomized to receive an IV-to-oral steroid regimen compared with those randomized to placebo.5 Patients receiving steroids also had shorter LOS and improvements in FEV1 after the first day of treatment. Subsequent randomized controlled trials in patients with AECOPD demonstrated the benefit of oral regimens compared with placebo with regard to FEV1, LOS, and risk of treatment failure.^6,7,8

Similarities in the bioavailability of oral and IV steroids have been known for a long time.⁹ Comparisons in efficacy initially were completed in the management of acute asthma exacerbations, with increasing evidence, including a meta-analysis, demonstrating no difference in improvement in pulmonary function and in preventing relapse of exacerbations for oral compared with IV steroids.¹⁰ However, only recently have oral and IV steroids been compared in the treatment of AECOPD. De Jong et al randomized more than 200 patients hospitalized for AECOPD to 60 mg of either IV or oral prednisolone for five days, followed by a week of an oral taper.¹¹ There were no significant differences in treatment failure between the IV and oral groups (62% vs. 56%, respectively, at 90 days; one-sided lower bound of the 95% confidence interval [CI], −5.8%).

click for large version

A large observational study by Lindenauer et al, including nearly 80,000 AECOPD patients admitted at more than 400 hospitals, added further support to the idea that oral and IV steroids were comparable in efficacy.¹² In this study, multivariate analysis found no difference in treatment failure between oral and IV groups (odds ratio [OR] 0.93; 95% CI, 0.84-1.02). The authors also found, however, that current clinical practice still overwhelmingly favors intravenous steroids, with 92% of study patients initially being administered IV steroids.¹²

Based on the evidence from de Jong and Lindenauer, it appears that there is no significant benefit to the use of IV over oral steroids. Additionally, there is evidence for oral administration being associated with beneficial effects on cost and hospital LOS.¹² Oral steroids, therefore, are the preferred route of administration to treat a hospitalized patient with AECOPD, unless the patient is unable to tolerate oral medications. Current guidelines support the practice of giving oral steroids as first-line treatment for AECOPD (see Table 2, above).

High dose vs. low dose. Another important clinical issue concerns the dosing of steroids. The randomized trials examining the use of corticosteroids in AECOPD vary widely in the dosages studied. Further, the majority of these trials have compared steroids to placebo, rather than comparing different dosage regimens. The agents studied have included prednisone, prednisolone, methylprednisolone, and hydrocortisone, or combinations thereof. In order to compare regimens of these different drugs, steroid doses often are converted into prednisone equivalents (see Table 3, below). Though no guidelines define “high dose” and “low dose,” some studies have designated doses of >80 mg prednisone equivalents daily as high-dose and prednisone equivalents of ≤80 mg daily as low-dose.^13,14

click for large version

Starting doses of systemic corticosteroids in the treatment of AECOPD in clinical studies range from prednisone equivalents of 30 mg daily to 625 mg on the first day of treatment.^5,8 No randomized studies of high- versus low-dose steroid regimens have been conducted. One retrospective chart review of 145 AECOPD admissions evaluated outcomes among patients who were given higher (mean daily dose >80 mg prednisone equivalent) and lower (mean daily dose of ≤80 mg prednisone) doses.¹⁴ The authors found that patients who received higher doses of steroids had significantly longer LOS compared with those who received lower doses, especially among the subset of patients who were admitted to the floor rather than the ICU, though this analysis did not adjust for severity of illness. In this study, the most striking finding noted by the authors was the wide variability in the steroid doses prescribed for the inpatient treatment of AECOPD.

More recently, the study by Lindenauer et al examined outcomes between patients treated with high-dose IV steroids (equivalent of 120 mg-800 mg of prednisone on the first or second day of treatment) compared to low-dose oral steroids (prednisone equivalents of 20 mg-80 mg per day).¹² The authors found no differences between the two groups regarding the rate of treatment failure, defined by initiation of mechanical ventilation after the second hospital day, in-hospital mortality, or readmission for COPD within 30 days of discharge. After multivariate adjustment, including the propensity for oral treatment, the low-dose oral therapy group was found to have lower risk of treatment failure, shorter LOS, and lower total hospital cost.

Despite the heterogeneity of the published data and the lack of randomized trials, the existing evidence suggests that low-dose prednisone (or equivalent) is similar in efficacy to higher doses and generally is associated with shorter hospital stays. Recognizing these benefits, guidelines do favor initiating treatment with low-dose steroids in patients admitted with AECOPD. The most recent publications from the American Thoracic Society/European Respiratory Society Task Force (ATS/ERS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Clinical Guidelines Centre in the United Kingdom, and the Canadian Thoracic Society all recommend equivalent dosing of prednisone in patients admitted with AECOPD who are able to tolerate oral intake (see Table 2).^1,2,15,16

Duration. As with the dosing of systemic corticosteroids in AECOPD, the optimal duration of treatment is not well-established. National and international consensus panels vary in their recommendations, as outlined in Table 2. This may be related to the variability in length of treatment found in the literature.

Treatment durations ranging from one day to eight weeks have been studied in inpatients with AECOPD. The landmark randomized controlled trial by Niewoehner and colleagues compared two-week and eight-week courses of systemic corticosteroids and found no difference in the rates of treatment failure, which included death, need for mechanical ventilation, readmission for COPD, and intensification of pharmacologic therapy.⁵ Based on these results, many experts have concluded that there is no benefit to steroid courses lasting beyond two weeks.

Although improvements in outcomes have been demonstrated with corticosteroid regimens as short as three days compared with placebo, most of the randomized controlled trials have included courses of seven to 14 days.⁴ Given the risks of adverse events (e.g. hyperglycemia) that are associated with systemic administration of steroids, the shortest effective duration should be considered.

click for large version

In both clinical practice and clinical studies, steroid regimens often include a taper. A study by Vondracek and Hemstreet found that 79% of hospital discharges for AECOPD included a tapered corticosteroid regimen.¹⁴ From a physiologic standpoint, durations of corticosteroid treatment approximately three weeks or less, regardless of dosage, should not lead to adrenal suppression.¹⁷ There also is no evidence to suggest that abrupt discontinuation of steroids leads to clinical worsening of disease, and complicated steroid tapers are a potential source of medication errors after hospital discharge.¹⁸ Furthermore, the clinical guidelines do not address the tapering of corticosteroids. Therefore, there is a lack of evidence advocating for or against the use of tapered steroid regimens in AECOPD.

Back to the Case

In addition to standard treatment modalities for AECOPD, our patient was administered oral prednisone 40 mg daily. She experienced steroid-induced hyperglycemia, which was corrected with adjustment of her insulin regimen. The patient’s pulmonary symptoms improved within 72 hours, and she was discharged home on hospital day four to complete a seven-day steroid course. At hospital discharge, she was administered influenza and pneumococcal vaccinations, and she was instructed to resume her usual insulin dosing once she finished her prednisone course.

Overview

In the management of AECOPD, there remains a lack of consensus in defining the ideal steroid regimen. Based on current literature, the use of low-dose oral corticosteroids, such as prednisone 40 mg daily, for a seven- to 14-day course is recommended. TH

Dr. Cunningham is an assistant professor of internal medicine and academic hospitalist in the section of hospital medicine at Vanderbilt University School of Medicine in Nashville, Tenn. Dr. LaBrin is an assistant professor of internal medicine and pediatrics and academic hospitalist at Vanderbilt University School of Medicine.

References

1. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Global Initiative for Chronic Obstructive Lung Disease website. Available at: www.goldcopd.org/GuidelineItem.asp?intId=989. Accessed Feb. 21, 2011.
2. Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.
3. Morbidity and mortality: 2009 chart book on cardiovascular, lung, and blood diseases. National Institutes of Health’s National Heart, Lung, and Blood Institute website. Available at: www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed Feb. 24, 2011.
4. Albert RK, Martin TR, Lewis SW. Controlled trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency. Ann Intern Med. 1980;92(6):753-758.
5. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941-1947.
6. Thompson WH, Nielson C, Carvalho P, Charan NB, Crowley JJ. Controlled trial of oral prednisone in outpatients with acute COPD exacerbation. Am J Respir Crit Care Med. 1996;154:407-412.
7. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161:1608-1613.
8. Davies L, Angus RM, Calverley PM. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet. 1999;354(9177):456-460.
9. Al-Habet S, Rogers HJ. Pharmacokinetics of intravenous and oral prednisolone. Br J Clin Pharmacol. 1980;10(5):503-508.
10. Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. 1992;10:301-310.
11. De Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: A randomized, controlled, double-blind study. Chest. 2007;132(6):1741-1747.
12. Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359-2367.
13. Manser R, Reid D, Abramsom MJ. Corticosteroids for acute severe asthma in hospitalized patients. Cochrane Database Syst Rev. 2000;(2):CD001740.
14. Vondracek SF, Hemstreet BA. Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2006;63:645-652.
15. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Institute for Health and Clinical Excellence website. Available at: guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed Feb. 21, 2011.
16. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease—2007 update. Can Respir J. 2007;14 Suppl B:5B-32B.
17. Webb J, Clark TJ. Recovery of plasma corticotrophin and cortisol levels after three-week course of prednisolone. Thorax. 1981;36:22-24.
18. O’Driscoll BR, Kalra S, Wilson M, Pickering CA, Carroll KB, Woodcock AA. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993; 341:324-7.

click for large version

Case

A 66-year-old Caucasian female with moderate chronic obstructive pulmonary disease (COPD) (FEV1 55% predicted), obesity, hypertension, and Type 2 diabetes mellitus on insulin therapy presents to the ED with four days of increased cough productive of yellow sputum and progressive shortness of breath. Her physical exam is notable for an oxygen saturation of 87% on room air, along with diffuse expiratory wheezing with use of accessory muscles; her chest X-ray is unchanged from previous. The patient is given oxygen, nebulized bronchodilators, and one dose of IV methylprednisolone. Her symptoms do not improve significantly, and she is admitted for further management. What regimen of corticosteroids is most appropriate to treat her acute exacerbation of COPD?

Overview

COPD is the fourth-leading cause of death in the United States and continues to increase in prevalence.1 Acute exacerbations of COPD (AECOPD) contribute significantly to this high mortality rate, which approaches 40% at one year in those patients requiring mechanical support.¹ An exacerbation of COPD has been defined as an acute change in a patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.² Exacerbations commonly occur in COPD patients and often necessitate hospital admission. In fact, COPD consistently is one of the 10 most common reasons for hospitalization, with billions of dollars in associated healthcare costs.³

The goals for inpatient management of AECOPD are to provide acute symptom relief and to minimize the potential for subsequent exacerbations. These are accomplished via a multifaceted approach, including the use of bronchodilators, antibiotics, supplemental oxygen, noninvasive positive pressure ventilation in certain circumstances, and systemic corticosteroids.

The administration of systemic steroids in AECOPD has been prevalent for several decades, with initial studies showing positive effects on lung function, specifically FEV1.⁴ Studies have demonstrated the benefit of steroids in prolonging the time to subsequent exacerbation, reducing the rate of treatment failure, and reducing length of stay (LOS).⁵ Corticosteroids have since become an essential component of the standard of care in AECOPD management.

Despite consensus that systemic steroids should be used in COPD exacerbations, a great deal of controversy still surrounds the optimal steroid regimen.⁶ Steroid use is not without risk, as steroids can lead to adverse outcomes in medically complex hospitalized patients (see Table 1, below). Current guidelines provide limited guidance as to the optimal route of administration, dosing regimen, or length of therapy; clinical practice varies widely.

Review of the Data

Administration route: intravenous (IV) vs. oral. The use of steroids in AECOPD began with such IV formulations as methylprednisolone, and this became the typical method of treating hospitalized patients. This practice was validated in a multicenter Veterans Affairs trial, which demonstrated decreased risk of treatment failure (defined as all-cause mortality, need for intubation, readmission for COPD, or intensification of pharmacologic therapy) for patients randomized to receive an IV-to-oral steroid regimen compared with those randomized to placebo.5 Patients receiving steroids also had shorter LOS and improvements in FEV1 after the first day of treatment. Subsequent randomized controlled trials in patients with AECOPD demonstrated the benefit of oral regimens compared with placebo with regard to FEV1, LOS, and risk of treatment failure.^6,7,8

Similarities in the bioavailability of oral and IV steroids have been known for a long time.⁹ Comparisons in efficacy initially were completed in the management of acute asthma exacerbations, with increasing evidence, including a meta-analysis, demonstrating no difference in improvement in pulmonary function and in preventing relapse of exacerbations for oral compared with IV steroids.¹⁰ However, only recently have oral and IV steroids been compared in the treatment of AECOPD. De Jong et al randomized more than 200 patients hospitalized for AECOPD to 60 mg of either IV or oral prednisolone for five days, followed by a week of an oral taper.¹¹ There were no significant differences in treatment failure between the IV and oral groups (62% vs. 56%, respectively, at 90 days; one-sided lower bound of the 95% confidence interval [CI], −5.8%).

click for large version

A large observational study by Lindenauer et al, including nearly 80,000 AECOPD patients admitted at more than 400 hospitals, added further support to the idea that oral and IV steroids were comparable in efficacy.¹² In this study, multivariate analysis found no difference in treatment failure between oral and IV groups (odds ratio [OR] 0.93; 95% CI, 0.84-1.02). The authors also found, however, that current clinical practice still overwhelmingly favors intravenous steroids, with 92% of study patients initially being administered IV steroids.¹²

Based on the evidence from de Jong and Lindenauer, it appears that there is no significant benefit to the use of IV over oral steroids. Additionally, there is evidence for oral administration being associated with beneficial effects on cost and hospital LOS.¹² Oral steroids, therefore, are the preferred route of administration to treat a hospitalized patient with AECOPD, unless the patient is unable to tolerate oral medications. Current guidelines support the practice of giving oral steroids as first-line treatment for AECOPD (see Table 2, above).

High dose vs. low dose. Another important clinical issue concerns the dosing of steroids. The randomized trials examining the use of corticosteroids in AECOPD vary widely in the dosages studied. Further, the majority of these trials have compared steroids to placebo, rather than comparing different dosage regimens. The agents studied have included prednisone, prednisolone, methylprednisolone, and hydrocortisone, or combinations thereof. In order to compare regimens of these different drugs, steroid doses often are converted into prednisone equivalents (see Table 3, below). Though no guidelines define “high dose” and “low dose,” some studies have designated doses of >80 mg prednisone equivalents daily as high-dose and prednisone equivalents of ≤80 mg daily as low-dose.^13,14

click for large version

Starting doses of systemic corticosteroids in the treatment of AECOPD in clinical studies range from prednisone equivalents of 30 mg daily to 625 mg on the first day of treatment.^5,8 No randomized studies of high- versus low-dose steroid regimens have been conducted. One retrospective chart review of 145 AECOPD admissions evaluated outcomes among patients who were given higher (mean daily dose >80 mg prednisone equivalent) and lower (mean daily dose of ≤80 mg prednisone) doses.¹⁴ The authors found that patients who received higher doses of steroids had significantly longer LOS compared with those who received lower doses, especially among the subset of patients who were admitted to the floor rather than the ICU, though this analysis did not adjust for severity of illness. In this study, the most striking finding noted by the authors was the wide variability in the steroid doses prescribed for the inpatient treatment of AECOPD.

More recently, the study by Lindenauer et al examined outcomes between patients treated with high-dose IV steroids (equivalent of 120 mg-800 mg of prednisone on the first or second day of treatment) compared to low-dose oral steroids (prednisone equivalents of 20 mg-80 mg per day).¹² The authors found no differences between the two groups regarding the rate of treatment failure, defined by initiation of mechanical ventilation after the second hospital day, in-hospital mortality, or readmission for COPD within 30 days of discharge. After multivariate adjustment, including the propensity for oral treatment, the low-dose oral therapy group was found to have lower risk of treatment failure, shorter LOS, and lower total hospital cost.

Despite the heterogeneity of the published data and the lack of randomized trials, the existing evidence suggests that low-dose prednisone (or equivalent) is similar in efficacy to higher doses and generally is associated with shorter hospital stays. Recognizing these benefits, guidelines do favor initiating treatment with low-dose steroids in patients admitted with AECOPD. The most recent publications from the American Thoracic Society/European Respiratory Society Task Force (ATS/ERS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Clinical Guidelines Centre in the United Kingdom, and the Canadian Thoracic Society all recommend equivalent dosing of prednisone in patients admitted with AECOPD who are able to tolerate oral intake (see Table 2).^1,2,15,16

Duration. As with the dosing of systemic corticosteroids in AECOPD, the optimal duration of treatment is not well-established. National and international consensus panels vary in their recommendations, as outlined in Table 2. This may be related to the variability in length of treatment found in the literature.

Treatment durations ranging from one day to eight weeks have been studied in inpatients with AECOPD. The landmark randomized controlled trial by Niewoehner and colleagues compared two-week and eight-week courses of systemic corticosteroids and found no difference in the rates of treatment failure, which included death, need for mechanical ventilation, readmission for COPD, and intensification of pharmacologic therapy.⁵ Based on these results, many experts have concluded that there is no benefit to steroid courses lasting beyond two weeks.

Although improvements in outcomes have been demonstrated with corticosteroid regimens as short as three days compared with placebo, most of the randomized controlled trials have included courses of seven to 14 days.⁴ Given the risks of adverse events (e.g. hyperglycemia) that are associated with systemic administration of steroids, the shortest effective duration should be considered.

click for large version

In both clinical practice and clinical studies, steroid regimens often include a taper. A study by Vondracek and Hemstreet found that 79% of hospital discharges for AECOPD included a tapered corticosteroid regimen.¹⁴ From a physiologic standpoint, durations of corticosteroid treatment approximately three weeks or less, regardless of dosage, should not lead to adrenal suppression.¹⁷ There also is no evidence to suggest that abrupt discontinuation of steroids leads to clinical worsening of disease, and complicated steroid tapers are a potential source of medication errors after hospital discharge.¹⁸ Furthermore, the clinical guidelines do not address the tapering of corticosteroids. Therefore, there is a lack of evidence advocating for or against the use of tapered steroid regimens in AECOPD.

Back to the Case

In addition to standard treatment modalities for AECOPD, our patient was administered oral prednisone 40 mg daily. She experienced steroid-induced hyperglycemia, which was corrected with adjustment of her insulin regimen. The patient’s pulmonary symptoms improved within 72 hours, and she was discharged home on hospital day four to complete a seven-day steroid course. At hospital discharge, she was administered influenza and pneumococcal vaccinations, and she was instructed to resume her usual insulin dosing once she finished her prednisone course.

Overview

In the management of AECOPD, there remains a lack of consensus in defining the ideal steroid regimen. Based on current literature, the use of low-dose oral corticosteroids, such as prednisone 40 mg daily, for a seven- to 14-day course is recommended. TH

Dr. Cunningham is an assistant professor of internal medicine and academic hospitalist in the section of hospital medicine at Vanderbilt University School of Medicine in Nashville, Tenn. Dr. LaBrin is an assistant professor of internal medicine and pediatrics and academic hospitalist at Vanderbilt University School of Medicine.

References

1. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Global Initiative for Chronic Obstructive Lung Disease website. Available at: www.goldcopd.org/GuidelineItem.asp?intId=989. Accessed Feb. 21, 2011.
2. Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.
3. Morbidity and mortality: 2009 chart book on cardiovascular, lung, and blood diseases. National Institutes of Health’s National Heart, Lung, and Blood Institute website. Available at: www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed Feb. 24, 2011.
4. Albert RK, Martin TR, Lewis SW. Controlled trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency. Ann Intern Med. 1980;92(6):753-758.
5. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941-1947.
6. Thompson WH, Nielson C, Carvalho P, Charan NB, Crowley JJ. Controlled trial of oral prednisone in outpatients with acute COPD exacerbation. Am J Respir Crit Care Med. 1996;154:407-412.
7. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161:1608-1613.
8. Davies L, Angus RM, Calverley PM. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet. 1999;354(9177):456-460.
9. Al-Habet S, Rogers HJ. Pharmacokinetics of intravenous and oral prednisolone. Br J Clin Pharmacol. 1980;10(5):503-508.
10. Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. 1992;10:301-310.
11. De Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: A randomized, controlled, double-blind study. Chest. 2007;132(6):1741-1747.
12. Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359-2367.
13. Manser R, Reid D, Abramsom MJ. Corticosteroids for acute severe asthma in hospitalized patients. Cochrane Database Syst Rev. 2000;(2):CD001740.
14. Vondracek SF, Hemstreet BA. Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2006;63:645-652.
15. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Institute for Health and Clinical Excellence website. Available at: guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed Feb. 21, 2011.
16. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease—2007 update. Can Respir J. 2007;14 Suppl B:5B-32B.
17. Webb J, Clark TJ. Recovery of plasma corticotrophin and cortisol levels after three-week course of prednisolone. Thorax. 1981;36:22-24.
18. O’Driscoll BR, Kalra S, Wilson M, Pickering CA, Carroll KB, Woodcock AA. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993; 341:324-7.

Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.

An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!

But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.

By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.

Bad Advice: Keeping Up with the Literature

There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.

But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?

Better Advice: Keep Up with Literature

I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.

The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.

Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.

Get a Gimmick: Good Advice?

It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)

On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”

But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.

He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.

I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.

It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.

For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.

If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.

An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!

But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.

By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.

Bad Advice: Keeping Up with the Literature

There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.

But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?

Better Advice: Keep Up with Literature

I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.

The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.

Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.

Get a Gimmick: Good Advice?

It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)

On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”

But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.

He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.

I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.

It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.

For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.

If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.

An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!

But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.

By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.

Bad Advice: Keeping Up with the Literature

There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.

But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?

Better Advice: Keep Up with Literature

I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.

The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.

Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.

Get a Gimmick: Good Advice?

It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)

On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”

But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.

He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.

I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.

It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.

For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.

If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I recently was appointed the director of my hospitalist group at a 53-bed hospital in rural Wisconsin. Including myself, we have three hospitalist FTEs, one part-time hospitalist, and one nurse practitioner; we are all seasoned internists, but we are relatively new to HM and the 24/7 nature of the business. The hospital administration has charged me with making the program more efficient. What do you suggest I do to improve our efficiency and standard of patient care?

Andrew Neubauer, DO, MPH

Dr. Hospitalist responds: Congratulations aside, one of the first items at hand is to understand the question being asked. Your hospital administration potentially has many moving parts: a CEO for vision, a chief operating officer (COO) for execution, a chief medical officer (CMO) for medical staff initiatives, and a chief financial officer (CFO) for the hard truth of hospital finances.

Before you take any steps to improve efficiency, you need to ask what “efficiency” means.

• Is it the CFO asking for better financial returns?
• Is the CEO trying to woo a large surgical group and needs to tout his high-functioning hospitalist group to make it more attractive?
• Does the CMO want to improve staff relations and primary-care referrals?
• Does the COO want higher patient satisfaction?

Whatever the answer is, the first thing to do is define the question. So, in a non-confrontational, inquisitive way, ask your administrators what they mean by “efficiency.”

The immediate corollary to this is that you must then get baseline data. You have to know where you are starting from in order to show demonstrable progress toward a goal. Whether it’s the case-mix index, the readmission rate, or adherence to protocols, defining the baseline and the goal is paramount.

Why is this so important? You need to be able to prove you met the goals, because as soon as you meet this one, a new one will be placed in front of you.

Let’s assume, by way of example, that “efficiency” in this case means an earlier time of discharge. For starters, ask what the average time of discharge is now, how it is measured, what the desired result is, and why. Once you have that information, look for ways that your group can improve, and make sure that the hospital is measuring you only on things you can control. Your physicians can determine the time the discharge order is written, but they have no say in when the patient physically leaves the building. It might seem like a subtle distinction, but it can make all the difference depending on how “time of discharge” is defined. Don’t promise what you can’t deliver—you’ll disappoint both the hospital and your practice partners.

Going forward, you should keep a playbook of past goals asked of you, and your group’s actions. This is incredibly important if (when) your contract comes up for renewal, since you will need to gently (and sometimes forcefully) remind the hospital of your group’s value. In addition, the other main constant in any hospital administration is change; last I checked, the average tenure for a hospital CEO is four years. You want to always be able to communicate your group’s achievements to serve as a visible reminder of your central role in the hospital.

As the newly appointed medical director, everyone is looking to you for answers. Just make sure to focus on the question first. TH

I recently was appointed the director of my hospitalist group at a 53-bed hospital in rural Wisconsin. Including myself, we have three hospitalist FTEs, one part-time hospitalist, and one nurse practitioner; we are all seasoned internists, but we are relatively new to HM and the 24/7 nature of the business. The hospital administration has charged me with making the program more efficient. What do you suggest I do to improve our efficiency and standard of patient care?

Andrew Neubauer, DO, MPH

Dr. Hospitalist responds: Congratulations aside, one of the first items at hand is to understand the question being asked. Your hospital administration potentially has many moving parts: a CEO for vision, a chief operating officer (COO) for execution, a chief medical officer (CMO) for medical staff initiatives, and a chief financial officer (CFO) for the hard truth of hospital finances.

Before you take any steps to improve efficiency, you need to ask what “efficiency” means.

• Is it the CFO asking for better financial returns?
• Is the CEO trying to woo a large surgical group and needs to tout his high-functioning hospitalist group to make it more attractive?
• Does the CMO want to improve staff relations and primary-care referrals?
• Does the COO want higher patient satisfaction?

Whatever the answer is, the first thing to do is define the question. So, in a non-confrontational, inquisitive way, ask your administrators what they mean by “efficiency.”

The immediate corollary to this is that you must then get baseline data. You have to know where you are starting from in order to show demonstrable progress toward a goal. Whether it’s the case-mix index, the readmission rate, or adherence to protocols, defining the baseline and the goal is paramount.

Why is this so important? You need to be able to prove you met the goals, because as soon as you meet this one, a new one will be placed in front of you.

Let’s assume, by way of example, that “efficiency” in this case means an earlier time of discharge. For starters, ask what the average time of discharge is now, how it is measured, what the desired result is, and why. Once you have that information, look for ways that your group can improve, and make sure that the hospital is measuring you only on things you can control. Your physicians can determine the time the discharge order is written, but they have no say in when the patient physically leaves the building. It might seem like a subtle distinction, but it can make all the difference depending on how “time of discharge” is defined. Don’t promise what you can’t deliver—you’ll disappoint both the hospital and your practice partners.

Going forward, you should keep a playbook of past goals asked of you, and your group’s actions. This is incredibly important if (when) your contract comes up for renewal, since you will need to gently (and sometimes forcefully) remind the hospital of your group’s value. In addition, the other main constant in any hospital administration is change; last I checked, the average tenure for a hospital CEO is four years. You want to always be able to communicate your group’s achievements to serve as a visible reminder of your central role in the hospital.

As the newly appointed medical director, everyone is looking to you for answers. Just make sure to focus on the question first. TH

I recently was appointed the director of my hospitalist group at a 53-bed hospital in rural Wisconsin. Including myself, we have three hospitalist FTEs, one part-time hospitalist, and one nurse practitioner; we are all seasoned internists, but we are relatively new to HM and the 24/7 nature of the business. The hospital administration has charged me with making the program more efficient. What do you suggest I do to improve our efficiency and standard of patient care?

Andrew Neubauer, DO, MPH

Dr. Hospitalist responds: Congratulations aside, one of the first items at hand is to understand the question being asked. Your hospital administration potentially has many moving parts: a CEO for vision, a chief operating officer (COO) for execution, a chief medical officer (CMO) for medical staff initiatives, and a chief financial officer (CFO) for the hard truth of hospital finances.

Before you take any steps to improve efficiency, you need to ask what “efficiency” means.

• Is it the CFO asking for better financial returns?
• Is the CEO trying to woo a large surgical group and needs to tout his high-functioning hospitalist group to make it more attractive?
• Does the CMO want to improve staff relations and primary-care referrals?
• Does the COO want higher patient satisfaction?

Whatever the answer is, the first thing to do is define the question. So, in a non-confrontational, inquisitive way, ask your administrators what they mean by “efficiency.”

The immediate corollary to this is that you must then get baseline data. You have to know where you are starting from in order to show demonstrable progress toward a goal. Whether it’s the case-mix index, the readmission rate, or adherence to protocols, defining the baseline and the goal is paramount.

Why is this so important? You need to be able to prove you met the goals, because as soon as you meet this one, a new one will be placed in front of you.

Let’s assume, by way of example, that “efficiency” in this case means an earlier time of discharge. For starters, ask what the average time of discharge is now, how it is measured, what the desired result is, and why. Once you have that information, look for ways that your group can improve, and make sure that the hospital is measuring you only on things you can control. Your physicians can determine the time the discharge order is written, but they have no say in when the patient physically leaves the building. It might seem like a subtle distinction, but it can make all the difference depending on how “time of discharge” is defined. Don’t promise what you can’t deliver—you’ll disappoint both the hospital and your practice partners.

Going forward, you should keep a playbook of past goals asked of you, and your group’s actions. This is incredibly important if (when) your contract comes up for renewal, since you will need to gently (and sometimes forcefully) remind the hospital of your group’s value. In addition, the other main constant in any hospital administration is change; last I checked, the average tenure for a hospital CEO is four years. You want to always be able to communicate your group’s achievements to serve as a visible reminder of your central role in the hospital.

As the newly appointed medical director, everyone is looking to you for answers. Just make sure to focus on the question first. TH

Click here to listen to Dr. Rosen

Click here to listen to Dr. Schnipper

Click here to listen to Dr. Rosen

Click here to listen to Dr. Schnipper

Click here to listen to Dr. Rosen

Click here to listen to Dr. Schnipper

Click here to listen to Dr. Kocher

Click here to listen to Dr. Kocher

Click here to listen to Dr. Kocher

Click here to listen to Dr. Li

Click here to listen to Dr. Li

Click here to listen to Dr. Li

GRAPEVINE, Texas—Community hospitalist compensation rose slightly last year to its highest level, according to preliminary SHM/MGMA survey data revealed at HM11. A national median wasn’t available, but SHM cofounder John Nelson, MD, MHM, says survey figures for compensation, including bonuses, rose roughly 3% over the prior year. Formal survey results are to be released in June.

According to Dr. Nelson, a nonacademic hospitalist in the Northeast seeing only adult patients earns roughly $212,000 per year. In the West, the number ticks up slightly to $213,000. Salaries rose at a higher rate in the Midwest (to $224,000) and the Southeast (to $246,000).

Sound Inpatient Physicians president and CEO Robert Bessler, MD, says survey data for compensation can be helpful but that individual HM groups need to be acutely aware of what hospitalists earn in their “micro-market” more than in their corner of the country. “The macro numbers are what they are,” he adds. “It’s not going to get less any time soon.”

Dr. Nelson also says that the average financial subsidy for HM groups has risen to $132,000 per FTE hospitalist, a marked jump from the roughly $100,000 level SHM reported in its past two surveys. Some 19% of hospitalist practices reported no support from their hospitals, a point that intrigues new SHM President Joseph Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston.

Dr. Li wonders how such a large percentage of practices operate independent of financial support, given that the vast majority of programs that do rely on that funding seem to be needing more of it. In short, he says: “Are we looking at two business models or two care models?”

Richard Quinn is a freelance writer based in New Jersey.

GRAPEVINE, Texas—Community hospitalist compensation rose slightly last year to its highest level, according to preliminary SHM/MGMA survey data revealed at HM11. A national median wasn’t available, but SHM cofounder John Nelson, MD, MHM, says survey figures for compensation, including bonuses, rose roughly 3% over the prior year. Formal survey results are to be released in June.

According to Dr. Nelson, a nonacademic hospitalist in the Northeast seeing only adult patients earns roughly $212,000 per year. In the West, the number ticks up slightly to $213,000. Salaries rose at a higher rate in the Midwest (to $224,000) and the Southeast (to $246,000).

Sound Inpatient Physicians president and CEO Robert Bessler, MD, says survey data for compensation can be helpful but that individual HM groups need to be acutely aware of what hospitalists earn in their “micro-market” more than in their corner of the country. “The macro numbers are what they are,” he adds. “It’s not going to get less any time soon.”

Dr. Nelson also says that the average financial subsidy for HM groups has risen to $132,000 per FTE hospitalist, a marked jump from the roughly $100,000 level SHM reported in its past two surveys. Some 19% of hospitalist practices reported no support from their hospitals, a point that intrigues new SHM President Joseph Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston.

Dr. Li wonders how such a large percentage of practices operate independent of financial support, given that the vast majority of programs that do rely on that funding seem to be needing more of it. In short, he says: “Are we looking at two business models or two care models?”

Richard Quinn is a freelance writer based in New Jersey.

GRAPEVINE, Texas—Community hospitalist compensation rose slightly last year to its highest level, according to preliminary SHM/MGMA survey data revealed at HM11. A national median wasn’t available, but SHM cofounder John Nelson, MD, MHM, says survey figures for compensation, including bonuses, rose roughly 3% over the prior year. Formal survey results are to be released in June.

According to Dr. Nelson, a nonacademic hospitalist in the Northeast seeing only adult patients earns roughly $212,000 per year. In the West, the number ticks up slightly to $213,000. Salaries rose at a higher rate in the Midwest (to $224,000) and the Southeast (to $246,000).

Sound Inpatient Physicians president and CEO Robert Bessler, MD, says survey data for compensation can be helpful but that individual HM groups need to be acutely aware of what hospitalists earn in their “micro-market” more than in their corner of the country. “The macro numbers are what they are,” he adds. “It’s not going to get less any time soon.”

Dr. Nelson also says that the average financial subsidy for HM groups has risen to $132,000 per FTE hospitalist, a marked jump from the roughly $100,000 level SHM reported in its past two surveys. Some 19% of hospitalist practices reported no support from their hospitals, a point that intrigues new SHM President Joseph Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston.

Dr. Li wonders how such a large percentage of practices operate independent of financial support, given that the vast majority of programs that do rely on that funding seem to be needing more of it. In short, he says: “Are we looking at two business models or two care models?”

Richard Quinn is a freelance writer based in New Jersey.

Click here to listen to Dr. Merli discuss the new anticoagulants

Click here to listen to Howard Bremer discuss the long history of warfarin

Click here to listen to Dr. Merli discuss the new anticoagulants

Click here to listen to Howard Bremer discuss the long history of warfarin

Click here to listen to Dr. Merli discuss the new anticoagulants

Click here to listen to Howard Bremer discuss the long history of warfarin