Internal Medicine Subspecialists Research Articles

Rheumatology: What You May Have Missed in 2023.

Many patients with rheumatologic conditions receive care from physicians other than rheumatologists. Here we note key findings from 6 studies in rheumatology published in 2023 that offer valuable insights for internal medicine specialists and subspecialists outside of rheumatology. The first study investigated the effect of low-dose glucocorticoids on patients with rheumatoid arthritis (RA) over 2 years and challenged existing perceptions about the risks of glucocorticoids in this setting. The second study focused on the updated guideline for preventing and treating glucocorticoid-induced osteoporosis. With the chronic and widespread use of glucocorticoids, the American College of Rheumatology emphasized the importance of assessing fracture risk and initiating pharmacologic therapy when appropriate. The third study explored the potential use of methotrexate in treating inflammatory hand osteoarthritis, suggesting a novel approach to managing this challenging and common condition. The results of the fourth article we highlight suggest that sarilumab has promise as an adjunct treatment of polymyalgia rheumatica relapse during glucocorticoid dosage tapering. The fifth study evaluated sublingual cyclobenzaprine for fibromyalgia treatment, noting both potential benefits and risks. Finally, the sixth article is a systematic review and meta-analysis that assessed the therapeutic equivalence of biosimilars and reference biologics in the treatment of patients with RA. Knowledge of this recent literature will be useful to clinicians regardless of specialty who care for patients with these commonly encountered conditions.

Oncology: What You May Have Missed in 2023.

Advances in oncology treatment methods have improved outcomes and quality of life for patients with cancer. However, care of these patients can be complex, and the contribution of physicians from different specialties is crucial. This article highlights important publications from 2023 on topics across a wide spectrum relating to the management of oncology patients. The literature was screened for significant new evidence that is relevant to internal medicine specialists and subspecialists whose focus is not oncology. Two articles address the importance of social interventions targeting end-of-life care for low-income and minority patients and the well-being of caregivers. Two additional articles address screening considerations in patients at risk for colorectal and lung cancer. Two more articles address safe use of hormone-related therapies to treat symptoms of menopause and prevent disease recurrence or progression in patients diagnosed with noninvasive breast neoplasia. Finally, several articles were included on topics related to COVID-19 vaccination in patients with cancer, use of cannabinoids for cancer pain control, chronic autoimmune adverse effects related to use of immune checkpoint inhibitors, and the incidence of second primary neoplasms.

Infectious Diseases: What You May Have Missed in 2023.

In 2023, published research on COVID-19 remains prominent. The aim of this article is to highlight important developments in infectious disease evidence unrelated to COVID-19 that were published in 2023. The literature was screened for sound new evidence relevant to internal medicine specialists and subspecialists whose focus of practice is not infectious diseases. The highlighted publications relate to various organisms and patient populations. One article provides insight into the updated guidelines for the diagnosis and management of infective endocarditis. Several articles address the management of sepsis and bacteremia: comparison of cefepime versus piperacillin-tazobactam, ceftobiprole for the treatment of complicated Staphylococcus aureus bacteremia, and early switch from intravenous to oral antibiotics in patients with gram-negative bacteremia. Another article examines differences in all-cause mortality in patients with Clostridioides difficile infection who receive different treatments. Additional articles provide evidence about the treatment of patients with HIV infection: the utility of preexposure prophylaxis to prevent HIV infection, the efficacy of pitavastatin in reducing cardiovascular disease, and the efficacy of dexamethasone for the treatment of tuberculous meningitis in persons with HIV.

Differences of bone quality in patients type II diabetes mellitus with mandibular cortical index analysis on panoramic radiograph

Objectives: This study aims to determine the quality of the mandibular cortex in Type II diabetes mellitus patients by analyzing the Mandibular Cortical Index on panoramic radiography. Materials and Methods: This type of research is unpaired comparative analytical design research using a cross-sectional stratified random sampling method and the Mann-Whitney statistical test. The subjects in this study were patients who visited and were diagnosed with type 2 DM for ≤ 5 years and > 5 years by doctors at the Endocrine Metabolic Internal Medicine Sub-Specialist Polyclinic, Ulin Hospital, Banjarmasin. Results: Respondents who had suffered ≤ 5 years had the highest mandibular cortical C2 index value of 10 (58.8%). Respondents who suffered > 5 years had the highest mandibular cortical C3 index value of 10 (58.8%). Diabetes mellitus patients with mandibular cortical C3 index value were ranked highest out of a total of 34 samples and were found in patients suffering from diabetes mellitus > 5 years. Conclusion: Patients with diabetes mellitus had poor bone quality, especially patients suffering from diabetes mellitus > 5 years.

Infectious Diseases: What You May Have Missed in 2022.

In 2022, COVID-19 remained the infectious disease at the top of most internal medicine physicians' minds. However, it was not the only infectious disease that was the topic of clinically relevant research that year. This article highlights some important infectious disease evidence unrelated to COVID-19 that was published in 2022. The literature was screened for sound new evidence relevant to internal medicine specialists and subspecialists whose focus of practice is not infectious diseases. The publications highlighted relate to various organisms in different patient populations. One article provides insight into the role of Helicobacter pylori eradication in the treatment of functional dyspepsia. The descriptive epidemiology of bacterial (Staphylococcus aureus) and viral (mpox) infections are the focus of 2 other articles. Several articles address the management of resistant and difficult-to-treat infections: multidrug-resistant gram-negative infections, resistant HIV-1, rifampin-resistant tuberculosis, cryptococcal meningitis, and invasive fungal infection in the setting of neutropenia. Another article provides data on effective HIV preexposure prophylaxis in women, an understudied population. Finally, given the urgent need to reduce inappropriate use of antibiotics, an article on antibiotic stewardship for hospitalized patients with presumed sepsis in a non-intensive care unit setting is also included.

Abstract A062: Age-, sex-, and race-related disparities in receipt of HypomethyLating Agents (HMA) for the treatment of myelodysplastic syndrome (MDS)

Abstract Objective: Recent data suggest low use of HMAs in patients with MDS in real world. We sought to identify factors associated with HMA use. Methods: Using 2011-2014 Medicare data, we identified individuals ³65 years of age diagnosed with incident MDS during the years 2012-2013 and receiving their care exclusively through the Medicare fee-for-service system. Collected data included age, race, sex, morbidity burden based on their frailty status (robust, pre-frail, mildly frail, moderately, or severely frail), nursing home residence, presence of MDS-related clinical characteristics [cytopenia (0-1 or ³2) and transfusion dependence (independent, low, or medium/high)], area-level socioeconomic measures [percent of individuals with income 100% below the federal poverty level; percent of adults (age > 25 years) without high school diploma; rurality, based on the rural-urban continuum code; and availability of general internal medicine subspecialists per 100,000 population], and receipt of bone marrow biopsy. Among those who received HMA, we grouped patients by the number of complete cycles (1-2, 3-5, or ³6). We used multivariable logistic regression analysis to evaluate the association between demographic characteristics and receipt of HMA, adjusting for MDS-related clinical characteristics, frailty, and socioeconomic measures. Results: Of 49,154 MDS pts, only 16.1% (7,935) received HMA. This percentage ranged from a low of 7.4% among individuals ³85 years of age to a high of 23.2% among those in the 65-74 age group. Receipt of HMA was significantly higher in men than in women (19.0% vs. 12.8%), in Whites than in minoritized patients (16.7% vs. 11.6% in Blacks, and 12.7% in those of Other race), higher among those with 2-3 cytopenias vs. 0-1 cytopenia and highest among those with medium/high transfusion dependence (44.7%). Among those who underwent biopsy, receipt of HMA was at 22.9%. Patients with moderate or severe frailty, and those in a nursing home had significantly lower rates of receipt of HMA. After adjusting for MDS-related clinical variables, frailty and socioeconomic measures, older patients had significantly lower odds than their younger counterparts to receive HMA [adjusted odds ratio (aOR): 0.84, (95% confidence interval: 0.79-0.89), and aOR: 0.43 (0.40-0.47) for those in the 75-84 and ³85 age groups, respectively). Females and minoritized patients had significantly lower odds than men and White patients to receive HMA [(aOR: 0.83 (0.79-0.88) for females; aOR: 0.71 (0.63-0.81) for Blacks, and aOR: 0.78 (0.68-0.89) for patients of Other race). Among those receiving HMA, we did not observe differences in the number of completed cycles by age, race, or sex. Conclusions: In Medicare beneficiaries with MDS, older patients, women, and minoritized patients have significantly lower odds to be treated with HMAs, even after adjusting for MDS-related clinical variables, morbidity burden, and socioeconomic measures. In addition to barriers to access adequate care, these results clearly reflect biases in MDS treatment, favoring younger, White men. Citation Format: Sudipto Mukherjee, Weichuan Dong, Aaron T. Gerds, Hetty E. Carraway, Abhay Singh, Anjali S. Advani, Siran M. Koroukian. Age-, sex-, and race-related disparities in receipt of HypomethyLating Agents (HMA) for the treatment of myelodysplastic syndrome (MDS) [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A062.

Critical Care Education and Skills Validation Course for Internal Medicine Physicians in the Military.

Military internist and internal medicine (IM) subspecialist physicians must be prepared to function in both traditional inpatient and outpatient settings, as well as manage critically ill patients within a deployed austere environment. As many critical care procedures are not performed on a routine basis in general IM practice, many active duty IM physicians experience skills degradation and lack confidence in performing these procedures. In order to address this perceived deficiency, the U.S. Army and Air Force Internal Medicine Education and Skills Validation Course was developed to provide essential training in critical care procedures for active duty military IM physicians and subspecialists. Staff internist and subspecialist physicians at multiple military treatment facilities participated in a 2-day simulation-based training course in critical care procedures included in the Army Individual Critical Task Lists and the Air Force Comprehensive Medical Readiness Program. Educational content included high-yield didactic lectures, multi-disciplinary Advanced Cardiac Life Support/Advanced Trauma Life Support high-fidelity simulation scenarios, and competency training/validation in various bedside procedures, including central venous and arterial line placement, trauma-focused ultrasound exam, airway management and endotracheal intubation, chest tube thoracotomy, and mechanical ventilation, among others. A total of 87 staff IM physicians participated in the course with an average of 2-4 years of experience following completion of graduate medical education. Upon course completion, all participants successfully achieved rigorous, checklist-based, standardized validation in all the required procedures. Survey data indicated a significant improvement in overall skills confidence, with 100% of participants indicating improvement in their ability to function independently as deployed medical officers. Broad implementation of this program at military hospitals would improve pre-deployment critical care procedural readiness in military IM physicians.

Rates and Characteristics of Medical Malpractice Claims Against Hospitalists.

Hospitalists practice in high-stakes and litigious settings. However, little data exist about the malpractice claims risk faced by hospitalists. To characterize the rates and characteristics of malpractice claims against hospitalists. An analysis was performed of malpractice claims against hospitalists, as well as against select other specialties, using data from a malpractice claims database that includes approximately 31% of US malpractice claims. For malpractice claims against hospitalists (n = 1,216) and comparator specialties (n = 18,644): claims rates (using a data subset), percentage of claims paid, median indemnity payment amounts, allegation types, and injury severity. Hospitalists had an annual malpractice claims rate of 1.95 claims per 100 physician-years, similar to that of nonhospitalist general internal medicine physicians (1.92 claims per 100 physician-years), and significantly greater than that of internal medicine subspecialists (1.30 claims per 100 physician-years) (P < .001). Claims rates for hospitalists nonsignificantly increased during the study period (2009-2018), whereas claims rates for four of the five other specialties examined significantly decreased over this period. The median indemnity payment for hospitalist claims was $231,454 (interquartile range, $100,000-$503,015), significantly higher than the amounts for all the other specialties except neurosurgery. The greatest predictor of a hospitalist case closing with payment (compared with no payment) was an error in clinical judgment as a contributing factor, with an adjusted odds ratio of 5.01 (95% CI, 3.37-7.45). During the study period, hospitalist claims rates did not drop, whereas they fell for other specialties. Hospitalists' claims had relatively high injury severity and median indemnity payment amounts. The malpractice environment for hospitalists is becoming less favorable.

CHARACTERISTIC OF ILLNESS PERCEPTION AND PHQ-9 SCORE IN CORONARY HEART DISEASE PATIENTS

Introduction: Coronary Heart Disease (CHD) accounts for the largest proportion of cardiovascular diseases. CHD patients may experience depressive symptoms or major depressive disorder. Patient Health Questionnaire (PHQ-9) Score has good sensitivity and specificity for patients with CHD. Negative illness perception is significantly associated with more severe levels of depression. The aim of this study is to understand the characteristics of the perception of illness and PHQ-9 scores in patients with CHD at Atma Jaya Hospital, Jakarta.&#x0D; Methods: A cross-sectional research was done on CHD patients in the clinic of Internal Medicine and Cardiac Sub-Specialist clinics, Cosmas outpatient unit in Atma Jaya Hospital over the course of September-October 2015. The Brief Illness Perception Questionnaire (BIPQ) and PHQ-9 were used to assess the characteristics of illness perception and determine the level of depression in patients with CHD. Univariate analysis were used to process the data.&#x0D; Results: 42 patients met the inclusion criteria. 62% of subjects had a positive perception of the disease and 38% had a negative perception. The highest average score of B-IPQ was the illness concern. Majority of the subjects 48.8% had minimal depression and none of the subject had severe depression.&#x0D; Conclusion: B-IPQ scores indicated positive illness perception and PHQ-9 shows minimal depression in most of CHD patients

Disparities in receipt of complete diagnostic evaluation to confirm myelodysplastic syndromes.

7555 Background: A complete diagnostic evaluation (CDE), including bone marrow (BM) biopsy, cytogenic testing, FISH panel, and/or flow cytometry, is widely accepted as a prerequisite for histopathologic confirmation of MDS. Earlier reports have raised concerns regarding accuracy of MDS diagnosis in population registries that do not require confirmatory tests for disease reporting. We queried Medicare files to analyze the extent of use of, and factors associated with CDE for diagnosing MDS. Methods: The study population included Medicare patients with at least one inpatient or two outpatient claims for MDS within a 12-month period during the years 2012 and 2013. Variables included age, sex, race, morphologic MDS categories, cytopenias (isolated or any combination), transfusion burden, comorbididities, as well as county-level characteristics (income, educational attainment, rurality, and availability of internal medicine subspecialists). Classification and regression tree (CART) and multivariable logistic regression analysis were used to identify combinations of factors associated with receipt of CDE. Results: Our study population included 45,067 MDS patients, of whom only 68.6% received CDE that included BM biopsy and/or chromosomal studies. The percent of patients undergoing CDE was significantly lower among those 85 years of age or older (56.1%); women (63.7%); Blacks (64.2%); patients with isolated anemia (60.3%); and those who were transfusion independent (p &lt; 0.001 for all comparisons). On the other hand, CDE was significantly higher among patients with the category of MDS with excess blasts (89.4%); those presenting with pancytopenia (92.2%); and those with high transfusion burden (80%). There was little variation by comorbidity burden, county level characteristics, or availability of subspecialists. In CART analysis, 80% of patients presenting with any two or more cytopenias received CDE. In multivariable analysis, advanced age, female sex, Black race, higher comorbidity burden and availability of subspecialists were associated with a lower likelihood to receive CDE, while patients with MDS with excess blasts, and with any &gt; 2 cytopenias were more likely to receive CDE ( P&lt; .0001). Conclusions: Nearly one third (31%) of MDS patients in the Medicare database lack CDE especially BM biopsy. Disparities in CDE can be corrected through proper physician education and stringent registry reporting to avoid such high diagnostic inaccuracies, leading to potential missed treatment opportunities.

An Inquiry Into the Early Careers of Master Clinicians

Residents and fellows often seek to emulate master clinician role models; however, the activities these expert clinical faculty pursued early in their careers are not known. We studied the early career clinical experiences and learning behaviors of peer-defined master academic clinicians. We performed a retrospective, qualitative interview study of 17 members of the University of California, San Francisco, Department of Medicine Council of Master Clinicians. Between March 1 and May 31, 2016, we interviewed participants using a semistructured interview guide surveying their early career clinical experiences and learning habits. Interviews were audio-recorded and transcribed. We used a general inductive approach to code transcripts and to identify consistent themes. Of the 28 council members invited to participate, 17 (61%) responded and were interviewed. Participants included 12 men and 5 women, with an average of 27 years in clinical practice (range, 13-50 years). Six participants were general internists, and 11 were internal medicine subspecialists. Based on thematic analysis of interview transcripts, 4 themes of clinical development emerged: (1) consistent learning efforts; (2) rigorous skill development; (3) cultivating habits of mind; and (4) clinically rich environments. Our study describes the early career experiences and learning behaviors of master clinicians. We aggregated key dimensions of the findings into a guide for residents, fellows, and junior clinicians interested in the pursuit of clinical excellence.

Transition to international classification of disease version 10, clinical modification: the impact on internal medicine and internal medicine subspecialties

BackgroundThe US health care system uses diagnostic codes for billing and reimbursement as well as quality assessment and measuring clinical outcomes. The US transitioned to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) on October, 2015. Little is known about the impact of ICD-10-CM on internal medicine and medicine subspecialists.MethodsWe used a state-wide data set from Illinois Medicaid specified for Internal Medicine providers and subspecialists. A total of 3191 ICD-9-CM codes were used for 51,078 patient encounters, for a total cost of US $26,022,022 for all internal medicine. We categorized all of the ICD-9-CM codes based on the complexity of mapping to ICD-10-CM as codes with complex mapping could result in billing or administrative errors during the transition. Codes found to have complex mapping and frequently used codes (n = 295) were analyzed for clinical accuracy of mapping to ICD-10-CM. Each subspecialty was analyzed for complexity of codes used and proportion of reimbursement associated with complex codes.ResultsTwenty-five percent of internal medicine codes have convoluted mapping to ICD-10-CM, which represent 22% of Illinois Medicaid patients, and 30% of reimbursements. Rheumatology and Endocrinology had the greatest proportion of visits and reimbursement associated with complex codes. We found 14.5% of ICD-9-CM codes used by internists, when mapped to ICD-10-CM, resulted in potential clinical inaccuracies.ConclusionsWe identified that 43% of diagnostic codes evaluated and used by internists and that account for 14% of internal medicine reimbursements are associated with codes which could result in administrative errors.

The Impact of Deployment on the Practice of the Military Internist: A Needs Assessment for Post-Deployment Refresher Training.

U.S. Army internists serve in a variety of provider roles during deployment, many of which vary from the traditional responsibilities of a general internist or internal medicine subspecialist. There is significant interest in defining specific clinical and procedural skills in which Army internists may require refresher training after deployment, but information to quantify and clarify these needs is lacking. An online, anonymous survey was created to assess Army internists' experience and comfort level with specialty-specific problems and procedures before and after deployment. This survey was distributed via the Army Central Simulation Committee to all U.S. Army internists eligible for deployment. The survey was available online from January 11, 2012, to March 9, 2012. Ninety-seven of all 115 (84%) U.S. Army internists eligible for deployment responded. The reported comfort level with core clinical problems in general internal medicine before and after deployment did not change, with the exception of decreased comfort with the performance of advanced cardiac life support (87% versus 76% comfortable, p = 0.035), evaluation and management of anemia (92% versus 83% comfortable, p = 0.039), and comfort with preoperative risk stratification and mitigation (81% versus 65% comfortable, p = 0.017). Providers' reported comfort level performing core internal medicine procedures decreased, including significant decreases with lumbar puncture (p < 0.001), arterial line placement (p = 0.02), ultrasound-guided central line placement (p = 0.01), ultrasound-guided thoracentesis (p = 0.004), and arthrocentesis (p = 0.01). Despite a reported deceased comfort with certain core clinical problems and procedural skills, only 10 of 68 (13%) respondents reported being offered refresher skills training following deployment. Although Army internists' comfort with core general internal medicine clinical problems remains largely unaffected by deployment, confidence in core internal medicine procedures suffers because of limited opportunities to practice these skills in the deployed setting. Skills training and assessment in procedures required for individual provider practice should be a primary focus of reintegration after deployment.

Challenges for internal medicine as the American College of Physicians celebrates its 100th anniversary.

Ideas and Opinions21 April 2015Challenges for Internal Medicine as the American College of Physicians Celebrates Its 100th AnniversarySteven E. Weinberger, MDSteven E. Weinberger, MDFrom the American College of Physicians, Philadelphia, Pennsylvania.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-2905 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail As the American College of Physicians (ACP) celebrates its 100th anniversary in 2015, it is an appropriate time to reflect on the current challenges and opportunities that face internal medicine specialists and subspecialists, their patients, and American society. The panoply of changes in health care delivery, new and proposed payment models, increasing regulatory requirements for physicians, and the unsustainable costs of health care certainly raise questions about future directions for health care and, specifically, for internal medicine. I highlight what I consider to be 3 leading issues for internal medicine and for ACP as it enters its second century and ...

Combat internist: the internal medicine experience in a combat hospital in Afghanistan.

Military internists and internal medicine subspecialists are physicians who generally work in traditional internal medicine settings. However, when deployed to combat settings, they must prepare and adapt their skills for a wide spectrum of complex, polytrauma, and multinational patients. There are limitations in personnel, equipment, and technical resources that make the circumstances complex and demanding. This article highlights some of the unique roles, challenges, and experiences of four military internists at the NATO Role 3, a deployed combat hospital in Afghanistan.

The Increasing Role of Nonradiologists in Performing Ultrasound-Guided Invasive Procedures

Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population. Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. Allowed billing claims submitted for USGP were extracted and volume was analyzed by provider type and setting. Compound annual growth rates were calculated. The total utilization rate for all USGP was 2,425 per 100,000 in 2004 and 4,870 in 2010, an increase of 100.8% (+2,445 per 100,000) with a compound annual growth rate of 12.3%. The year 2010 represents the first year that nonradiologists as a group performed more USGP than radiologists, at 922,672 versus 794,497 examinations, respectively. Nonradiologists accounted for 72.2% (599,751 of 830,925) of the USGP volume growth from 2004 to 2010. Most 2010 claims were submitted by radiologists (n = 794,497; 46.3%) and surgeons (n = 332,294; 19.4%). The largest overall volume increases from 2004 to 2010 were observed among radiologists, surgeons, anesthesiologists, rheumatologists, midlevel providers, primary care physicians, nonrheumatologist internal medicine subspecialists, and the aggregate of all other provider types. The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance.

Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? an observational comparative analysis of hospitalists vs. traditional care providers

BackgroundDespite the growth of hospitalist programs in Canada, little is known about their effectiveness for improving quality of care and use of scarce healthcare resources. The objective of this study is to compare measures of cost and quality of care (in-hospital mortality, 30-day same-facility readmission, and length of stay) of hospitalists vs. traditional physician providers in a large Canadian community hospital setting.MethodsWe performed a retrospective analysis of data from the Canadian Institute for Health Information (CIHI) Discharge Database, using multivariate logistic and linear regression analyses comparing performance of four provider groups of traditional family physicians (FPs), traditional internal medicine subspecialists (other-IM), family physician-trained hospitalists (FP-Hospitalist), and general internal medicine-trained hospitalists (GIM-Hospitalist).ResultsCompared to traditional FPs, FP-Hospitalists and GIM-Hospitalists demonstrate lower mortality [OR 0.881, (CI 0.779 – 0.996); and OR 0.355, (CI 0.288 – 0.436)] and readmission rates [OR 0.766, (CI 0.678 – 0.867); and OR 0.800, (CI 0.675 – 0.948)]. Compared to traditional FPs, GIM-Hospitalists appear to improve length of stay [OR−2.975, (CI −3.302 – -2.647)] while FP-Hospitalists perform similarly [OR 0.096, (CI −0.136 – 0.329)]. Compared to other-IM, GIM-Hospitalists have similar performance on all measures while FP-Hospitalists show a mixed impact.ConclusionsCompared to traditional family physicians, hospitalists appear to improve measures of quality and resource utilization. Specifically, hospitalists demonstrate lower in-hospital mortality and 30-day readmission rates while improving (or at least showing similar) length of stay. Compared to traditional subspecialists, hospitalists demonstrate similar performance despite looking after sicker and more complex medical patients.

An Approach to Preoperative Neurologic Consultation for Non-neurologic Surgery

Neurologists are commonly asked to provide outpatient or inpatient consultation prior to non-neurologic surgery in patients with an underlying neurologic disorder; however, a paucity of neurologic literature and no evidence-based guidelines exist regarding how to approach this common clinical problem. Extrapolating on the literature regarding the process of preoperative consultation by internists and internal medicine subspecialists, this article attempts to provide a general framework for the neurologist who is asked to evaluate a patient preoperatively. The importance of timely and effective communication, including discussion and clarification with the referring surgeon regarding the neurologist's role in each preoperative assessment, is stressed.

Consult the Hospitalist for Medical Management

Previous studies have shown that comanagement of surgical patients by medicine physicians (generalists or internal medicine subspecialists) is

Comanagement of Hospitalized Surgical Patients by Medicine Physicians in the United States

Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States. We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized. Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians. Medical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.