Affiliations
Department of Medicine, Harvard Medical School, Boston, Massachusetts
Given name(s)
Flora
Family name
Kisuule
Degrees
MD

SPEAKers at the National Society of Hospital Medicine Meeting: A Follow-UP Study of Gender Equity for Conference Speakers from 2015 to 2019. The SPEAK UP Study

Article Type
Changed
Thu, 03/25/2021 - 14:02

Persistent gender disparities exist in pay,1,2 leadership opportunities,3,4 promotion,5 and speaking opportunities.6 While the gender distribution of the hospitalist workforce may be approaching parity,3,7,8 gender differences in leadership, speakership, and authorship have already been noted in hospital medicine.3 Between 2006 and 2012, women constituted less than a third (26%) of the presenters at the national conferences of the Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM).3

The SHM Annual Meeting has historically had an “open call” peer review process for workshop presenters with the goal of increasing the diversity of presenters. In 2019, this process was expanded to include didactic speakers. Our aim in this study was to assess whether these open call procedures resulted in improved representation of women speakers and how the proportion of women speakers affects the overall evaluation scores of the conference. Our hypothesis was that the introduction of an open call process for the SHM conference didactic speakers would be associated with an increased proportion of women speakers, compared with the closed call processes, without a negative impact on conference scores.

METHODS

The study is a retrospective evaluation of data collected regarding speakers at the annual SHM conference from 2015 to 2019. The SHM national conference typically has two main types of offerings: workshops and didactics. Workshop presenters from 2015 to 2019 were selected via an open call process as defined below. Didactic speakers (except for plenary speakers) were selected using the open call process for 2019 only.

We aimed to compare (1) the number and proportion of women speakers, compared with men speakers, over time and (2) the proportion of women speakers when open call processes were utilized versus that seen with closed call processes. Open call included workshops for all years and didactics for 2019; closed call included didactics for 2015 to 2018 and plenary sessions 2015 to 2019 (Table). The speaker list for the conferences was obtained from conference pamphlets or agendas available via Internet searches or obtained through attendance at the conference.

Speaker Categories and Identification Process

We determined whether each individual was a featured speaker (one whose talk was unopposed by other sessions), plenary speaker (defined as such in the conference pamphlets), whether they spoke in a group format, and whether the speaking opportunity type was a workshop or a didactic session. Numbers of featured and plenary speakers were combined because of low numbers. SHM provided deidentified conference evaluation data for each year studied. For the purposes of this study, we analyzed all speakers which included physicians, advanced practice providers, and professionals such as nurses and other interdisciplinary team members. The same speaker could be included multiple times if they had multiple speaking opportunities.

 

 

Open Call Process

We defined the “open call process” (referred to as “open call” here forward) as the process utilized by SHM that includes the following two components: (1) advertisements to members of SHM and to the medical community at large through a variety of mechanisms including emails, websites, and social media outlets and (2) an online submission process that includes names of proposed speakers and their topic and, in the case of workshops, session objectives as well as an outline of the proposed workshop. SHM committees may also submit suggestions for topics and speakers. Annual Conference Committee members then review and rate submissions on the categories of topic, organization and clarity, objectives, and speaker qualifications (with a focus on institutional, geographic, and gender diversity). Scores are assigned from 1 to 5 (with 5 being the best score) for each category and a section for comments is available. All submissions are also evaluated by the course director.

After initial committee reviews, scores with marked reviewer discrepancies are rereviewed and discussed by the committee and course director. A cutoff score is then calculated with proposals falling below the cutoff threshold omitted from further consideration. Weekly calls are then focused on subcategories (ie tracks) with emphasis on clinical and educational content. Each of the tracks have a subcommittee with track leads to curate the best content first and then focus on final speaker selection. More recently, templates are shared with the track leads that include a location to call out gender and institutional diversity. Weekly calls are held to hone the content and determine the speakers.

For the purposes of this study, when the above process was not used, the authors refer to it as “closed call.” Closed call processes do not typically involve open invitations or a peer review process. (Table)

Gender

Gender was assigned based on the speaker’s self-identification by the pronouns used in their biography submitted to the conference or on their institutional website or other websites where the speaker was referenced. Persons using she/her/hers pronouns were noted as women and persons using he/him/his were noted as men. For the purposes of this study, we conceptualized gender as binary (ie woman/man) given the limited information we had from online sources.

ANALYSIS

REDCap, a secure, Web-based application for building and managing online survey and databases, was used to collect and manage all study data.9

All analyses were performed using SAS Enterprise Guide 8.1 (SAS Institute, Inc., Cary, North Carolina) using retrospectively collected data. A Cochran-Armitage test for trend was used to evaluate the proportion of women speakers from 2015 to 2019. A chi-square test was used to assess the proportion of women speakers for open call processes versus that seen with closed call. One-way analysis of variance (ANOVA) was used to evaluate annual conference evaluation scores from 2015 to 2019. Either numbers with proportions or means with standard deviations have been reported. Bonferroni’s correction for multiple comparisons was applied, with a P < .008 considered statistically significant.

 

 

RESULTS

Between 2015 and 2019, a total of 709 workshop and didactic presentations were given by 1,261 speakers at the annual Society of Hospital Medicine Conference. Of these, 505 (40%) were women; 756 (60%) were men. There were no missing data.

From 2015 to 2019, representation of women speakers increased from 35% of all speakers to 47% of all speakers (P = .0068). Women plenary speakers increased from 23% in 2015 to 45% in 2019 (P = .0396).

The proportion of women presenters for workshops (which have utilized an open call process throughout the study period), ranged from 43% to 53% from 2015 to 2019 with no statistically significant difference in gender distribution across years (Figure).



A greater proportion of speakers selected by an open call process were women compared to when speakers were selected by a closed call process (261 (47%) vs 244 (34%); P < .0001).

Of didactics or workshops given in a group format (N = 299), 82 (27%) were given by all-men groups and 38 (13%) were given by all-women groups. Women speakers participating in all-women group talks accounted for 21% of all women speakers; whereas men speakers participating in all-men group talks account for 26% of all men speakers (P = .02). We found that all-men group speaking opportunities did decrease from 41% of group talks in 2015 to 21% of group talks in 2019 (P = .0065).

We saw an average 3% annual increase in women speakers from 2015 to 2019, an 8% increase from 2018 to 2019 for all speakers, and an 11% increase in women speakers specific to didactic sessions. Overall conference ratings increased from a mean of 4.3 ± 0.24 in 2015 to a mean of 4.6 ± 0.14 in 2019 (n = 1,202; P < .0001; Figure).

DISCUSSION

The important findings of this study are that there has been an increase in women speakers over the last 5 years at the annual Society of Hospital Medicine Conference, that women had higher representation as speakers when open call processes were followed, and that conference scores continued to improve during the time frame studied. These findings suggest that a systematic open call process helps to support equitable speaking opportunities for men and women at a national hospital medicine conference without a negative impact on conference quality.

To recruit more diverse speakers, open call and peer review processes were used in addition to deliberate efforts at ensuring diversity in speakers. We found that over time, the proportion of women with speaking opportunities increased from 2015 to 2019. Interestingly, workshops, which had open call processes in place for the duration of the study period, had almost equal numbers of men and women presenting in all years. We also found that the number of all-men speaking groups decreased between 2015 and 2019.

A single process change can impact gender equity, but the target of true equity is expected to require additional measures such as assessment of committee structures and diversity, checklists, and reporting structures (data analysis and plans when goals not achieved).10-13 For instance, the American Society for Microbiology General Meeting was able to achieve gender equity in speakers by a multifold approach including ensuring the program committee was aware of gender statistics, increasing female representation among session convener teams, and direct instruction to try to avoid all-male sessions.11

It is important to acknowledge that these processes do require valuable resources including time. SHM has historically used committee volunteers to conduct the peer review process with each committee member reviewing 20 to 30 workshop submissions and 30 to 50 didactic sessions. While open processes with peer review seem to generate improved gender equity, ensuring processes are in place during the selection process is also key.

Several recent notable efforts to enhance gender equity and to increase diversity have been proposed. One such example of a process that may further improve gender equity was proposed by editors at the Journal of Hospital Medicine to assess current representation via demographics including gender, race, and ethnicity of authors with plans to assess patterns in the coming years.14 The American College of Physicians also published a position paper on achieving gender equity with a recommendation that organizational policies and procedures should be implemented that address implicit bias.15

Our study showed that, from 2015 to 2019, conference evaluations saw a significant increase in the score concurrently with the rise in proportion of women speakers. This finding suggests that quality does not seem to be affected by this new methodology for speaker selection and in fact this methodology may actually help improve the overall quality of the conference. To our knowledge, this is one of the first studies to concurrently evaluate speaker gender equity with conference quality.

Our study offers several strengths. This study took a pragmatic approach to understanding how processes can impact gender equity, and we were able to take advantage of the evolution of the open call system (ie workshops which have been an open call process for the duration of the study versus speaking opportunities that were not).

Our study also has several limitations. First, this study is retrospective in nature and thus other processes could have contributed to the improved gender equity, such as an organization’s priorities over time. During this study period, the SHM conference saw an average 3% increase annually in women speakers and an increase of 8% from 2018 to 2019 for all speakers compared to national trends of approximately 1%,6 which suggests that the open call processes in place could be contributing to the overall increases seen. Similarly, because of the retrospective nature of the study, we cannot be certain that the improvements in conference scores were directly the result of improved gender equity, although it does suggest that the improvements in gender equity did not have an adverse impact on the scores. We also did not assess how the composition of selection committee members for the meeting could have impacted the overall composition of the speakers. Our study looked at diversity only from the perspective of gender in a binary fashion, and thus additional studies are needed to assess how to improve diversity overall. It is unclear how this new open call for speakers affects race and ethnic diversity specifically. Identifying gender for the purposes of this study was facilitated by speakers providing their own biographies and the respective pronouns used in those biographies, and thus gender was easier to ascertain than race and ethnicity, which are not as readily available. For organizations to understand their diversity, equity, and inclusion efforts, enhancing the ability to fairly track and measure diversity will be key. Lastly, understanding of the exact composition of hospitalists from both a gender and race/ethnicity perspective is lacking. Studies have suggested that, based upon those surveyed or studied, there is a fairly equal balance of men and women albeit in academic groups.3

 

 

CONCLUSIONS

An open call approach to speakers at a national hospitalist conference seems to have contributed to improvements regarding gender equity in speaking opportunities with a concurrent improvement in overall rating of the conference. The open call system is a potential mechanism that other institutions and organizations could employ to enhance their diversity efforts.

Acknowledgments

Society of Hospital Medicine Diversity, Equity, Inclusion Special Interest Group

Work Group for SPEAK UP: Marisha Burden, MD, Daniel Cabrera, MD, Amira del Pino-Jones, MD, Areeba Kara, MD, Angela Keniston, MSPH, Keshav Khanijow, MD, Flora Kisuule, MD, Chiara Mandel, Benji Mathews, MD, David Paje, MD, Stephan Papp, MD, Snehal Patel, MD, Suchita Shah Sata, MD, Dustin Smith, MD, Kevin Vuernick

References

1. Weaver AC, Wetterneck TB, Whelan CT, Hinami K. A matter of priorities? Exploring the persistent gender pay gap in hospital medicine. J Hosp Med. 2015;10(8):486-490. https://doi.org/10.1002/jhm.2400.
2. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. https://doi.org/10.1001/jamainternmed.2016.3284.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med. 2015;10(8):481-485. https://doi.org/10.1002/jhm.2340.
4. Silver JK, Ghalib R, Poorman JA, et al. Analysis of gender equity in leadership of physician-focused medical specialty societies, 2008-2017. JAMA Intern Med. 2019;179(3):433-435. https://doi.org/10.1001/jamainternmed.2018.5303.
5. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA. 2015;314(11):1149-1158. https://doi.org/10.1001/jama.2015.10680.
6. Ruzycki SM, Fletcher S, Earp M, Bharwani A, Lithgow KC. Trends in the Proportion of Female Speakers at Medical Conferences in the United States and in Canada, 2007 to 2017. JAMA Netw Open. 2019;2(4):e192103. https://doi.org/10.1001/jamanetworkopen.2019.2103
7. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27. https://doi.org/10.1007/s11606-011-1892-5.
8. Today’s Hospitalist 2018 Compensation and Career Survey Results. https://www.todayshospitalist.com/salary-survey-results/. Accessed September 28, 2019.
9. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. https://doi.org/10.1016/j.jbi.2008.08.010.
10. Burden M, del Pino-Jones A, Shafer M, Sheth S, Rexrode K. Association of American Medical Colleagues (AAMC) Group on Women in Medicine and Science. Recruitment Toolkit: https://www.aamc.org/download/492864/data/equityinrecruitmenttoolkit.pdf. Accessed July 27, 2019.
11. Casadevall A. Achieving speaker gender equity at the american society for microbiology general meeting. MBio. 2015;6:e01146. https://doi.org/10.1128/mBio.01146-15.
12. Westring A, McDonald JM, Carr P, Grisso JA. An integrated framework for gender equity in academic medicine. Acad Med. 2016;91(8):1041-1044. https://doi.org/10.1097/ACM.0000000000001275.
13. Martin JL. Ten simple rules to achieve conference speaker gender balance. PLoS Comput Biol. 2014;10(11):e1003903. https://doi.org/10.1371/journal.pcbi.1003903.
14. Shah SS, Shaughnessy EE, Spector ND. Leading by example: how medical journals can improve representation in academic medicine. J Hosp Med. 2019;14(7):393. https://doi.org/10.12788/jhm.3247.
15. Butkus R, Serchen J, Moyer DV, et al. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med. 2018;168:721-723. https://doi.org/10.7326/M17-3438.

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1Denver Health, Denver, Colorado; 2Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado; 3University of Colorado School of Medicine, Aurora, Colorado; 4Indiana University School of Medicine, Indianapolis, Indiana; 5Division of Hospital Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; 6Society of Hospital Medicine, Philadelphia, Pennsylvania; 7Regions Hospital, HealthPartners, Saint Paul, Minnesota; 8Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia.

Disclosures

The authors report no conflicts of interest.

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Disclosures

The authors report no conflicts of interest.

Author and Disclosure Information

1Denver Health, Denver, Colorado; 2Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado; 3University of Colorado School of Medicine, Aurora, Colorado; 4Indiana University School of Medicine, Indianapolis, Indiana; 5Division of Hospital Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; 6Society of Hospital Medicine, Philadelphia, Pennsylvania; 7Regions Hospital, HealthPartners, Saint Paul, Minnesota; 8Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia.

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Related Articles

Persistent gender disparities exist in pay,1,2 leadership opportunities,3,4 promotion,5 and speaking opportunities.6 While the gender distribution of the hospitalist workforce may be approaching parity,3,7,8 gender differences in leadership, speakership, and authorship have already been noted in hospital medicine.3 Between 2006 and 2012, women constituted less than a third (26%) of the presenters at the national conferences of the Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM).3

The SHM Annual Meeting has historically had an “open call” peer review process for workshop presenters with the goal of increasing the diversity of presenters. In 2019, this process was expanded to include didactic speakers. Our aim in this study was to assess whether these open call procedures resulted in improved representation of women speakers and how the proportion of women speakers affects the overall evaluation scores of the conference. Our hypothesis was that the introduction of an open call process for the SHM conference didactic speakers would be associated with an increased proportion of women speakers, compared with the closed call processes, without a negative impact on conference scores.

METHODS

The study is a retrospective evaluation of data collected regarding speakers at the annual SHM conference from 2015 to 2019. The SHM national conference typically has two main types of offerings: workshops and didactics. Workshop presenters from 2015 to 2019 were selected via an open call process as defined below. Didactic speakers (except for plenary speakers) were selected using the open call process for 2019 only.

We aimed to compare (1) the number and proportion of women speakers, compared with men speakers, over time and (2) the proportion of women speakers when open call processes were utilized versus that seen with closed call processes. Open call included workshops for all years and didactics for 2019; closed call included didactics for 2015 to 2018 and plenary sessions 2015 to 2019 (Table). The speaker list for the conferences was obtained from conference pamphlets or agendas available via Internet searches or obtained through attendance at the conference.

Speaker Categories and Identification Process

We determined whether each individual was a featured speaker (one whose talk was unopposed by other sessions), plenary speaker (defined as such in the conference pamphlets), whether they spoke in a group format, and whether the speaking opportunity type was a workshop or a didactic session. Numbers of featured and plenary speakers were combined because of low numbers. SHM provided deidentified conference evaluation data for each year studied. For the purposes of this study, we analyzed all speakers which included physicians, advanced practice providers, and professionals such as nurses and other interdisciplinary team members. The same speaker could be included multiple times if they had multiple speaking opportunities.

 

 

Open Call Process

We defined the “open call process” (referred to as “open call” here forward) as the process utilized by SHM that includes the following two components: (1) advertisements to members of SHM and to the medical community at large through a variety of mechanisms including emails, websites, and social media outlets and (2) an online submission process that includes names of proposed speakers and their topic and, in the case of workshops, session objectives as well as an outline of the proposed workshop. SHM committees may also submit suggestions for topics and speakers. Annual Conference Committee members then review and rate submissions on the categories of topic, organization and clarity, objectives, and speaker qualifications (with a focus on institutional, geographic, and gender diversity). Scores are assigned from 1 to 5 (with 5 being the best score) for each category and a section for comments is available. All submissions are also evaluated by the course director.

After initial committee reviews, scores with marked reviewer discrepancies are rereviewed and discussed by the committee and course director. A cutoff score is then calculated with proposals falling below the cutoff threshold omitted from further consideration. Weekly calls are then focused on subcategories (ie tracks) with emphasis on clinical and educational content. Each of the tracks have a subcommittee with track leads to curate the best content first and then focus on final speaker selection. More recently, templates are shared with the track leads that include a location to call out gender and institutional diversity. Weekly calls are held to hone the content and determine the speakers.

For the purposes of this study, when the above process was not used, the authors refer to it as “closed call.” Closed call processes do not typically involve open invitations or a peer review process. (Table)

Gender

Gender was assigned based on the speaker’s self-identification by the pronouns used in their biography submitted to the conference or on their institutional website or other websites where the speaker was referenced. Persons using she/her/hers pronouns were noted as women and persons using he/him/his were noted as men. For the purposes of this study, we conceptualized gender as binary (ie woman/man) given the limited information we had from online sources.

ANALYSIS

REDCap, a secure, Web-based application for building and managing online survey and databases, was used to collect and manage all study data.9

All analyses were performed using SAS Enterprise Guide 8.1 (SAS Institute, Inc., Cary, North Carolina) using retrospectively collected data. A Cochran-Armitage test for trend was used to evaluate the proportion of women speakers from 2015 to 2019. A chi-square test was used to assess the proportion of women speakers for open call processes versus that seen with closed call. One-way analysis of variance (ANOVA) was used to evaluate annual conference evaluation scores from 2015 to 2019. Either numbers with proportions or means with standard deviations have been reported. Bonferroni’s correction for multiple comparisons was applied, with a P < .008 considered statistically significant.

 

 

RESULTS

Between 2015 and 2019, a total of 709 workshop and didactic presentations were given by 1,261 speakers at the annual Society of Hospital Medicine Conference. Of these, 505 (40%) were women; 756 (60%) were men. There were no missing data.

From 2015 to 2019, representation of women speakers increased from 35% of all speakers to 47% of all speakers (P = .0068). Women plenary speakers increased from 23% in 2015 to 45% in 2019 (P = .0396).

The proportion of women presenters for workshops (which have utilized an open call process throughout the study period), ranged from 43% to 53% from 2015 to 2019 with no statistically significant difference in gender distribution across years (Figure).



A greater proportion of speakers selected by an open call process were women compared to when speakers were selected by a closed call process (261 (47%) vs 244 (34%); P < .0001).

Of didactics or workshops given in a group format (N = 299), 82 (27%) were given by all-men groups and 38 (13%) were given by all-women groups. Women speakers participating in all-women group talks accounted for 21% of all women speakers; whereas men speakers participating in all-men group talks account for 26% of all men speakers (P = .02). We found that all-men group speaking opportunities did decrease from 41% of group talks in 2015 to 21% of group talks in 2019 (P = .0065).

We saw an average 3% annual increase in women speakers from 2015 to 2019, an 8% increase from 2018 to 2019 for all speakers, and an 11% increase in women speakers specific to didactic sessions. Overall conference ratings increased from a mean of 4.3 ± 0.24 in 2015 to a mean of 4.6 ± 0.14 in 2019 (n = 1,202; P < .0001; Figure).

DISCUSSION

The important findings of this study are that there has been an increase in women speakers over the last 5 years at the annual Society of Hospital Medicine Conference, that women had higher representation as speakers when open call processes were followed, and that conference scores continued to improve during the time frame studied. These findings suggest that a systematic open call process helps to support equitable speaking opportunities for men and women at a national hospital medicine conference without a negative impact on conference quality.

To recruit more diverse speakers, open call and peer review processes were used in addition to deliberate efforts at ensuring diversity in speakers. We found that over time, the proportion of women with speaking opportunities increased from 2015 to 2019. Interestingly, workshops, which had open call processes in place for the duration of the study period, had almost equal numbers of men and women presenting in all years. We also found that the number of all-men speaking groups decreased between 2015 and 2019.

A single process change can impact gender equity, but the target of true equity is expected to require additional measures such as assessment of committee structures and diversity, checklists, and reporting structures (data analysis and plans when goals not achieved).10-13 For instance, the American Society for Microbiology General Meeting was able to achieve gender equity in speakers by a multifold approach including ensuring the program committee was aware of gender statistics, increasing female representation among session convener teams, and direct instruction to try to avoid all-male sessions.11

It is important to acknowledge that these processes do require valuable resources including time. SHM has historically used committee volunteers to conduct the peer review process with each committee member reviewing 20 to 30 workshop submissions and 30 to 50 didactic sessions. While open processes with peer review seem to generate improved gender equity, ensuring processes are in place during the selection process is also key.

Several recent notable efforts to enhance gender equity and to increase diversity have been proposed. One such example of a process that may further improve gender equity was proposed by editors at the Journal of Hospital Medicine to assess current representation via demographics including gender, race, and ethnicity of authors with plans to assess patterns in the coming years.14 The American College of Physicians also published a position paper on achieving gender equity with a recommendation that organizational policies and procedures should be implemented that address implicit bias.15

Our study showed that, from 2015 to 2019, conference evaluations saw a significant increase in the score concurrently with the rise in proportion of women speakers. This finding suggests that quality does not seem to be affected by this new methodology for speaker selection and in fact this methodology may actually help improve the overall quality of the conference. To our knowledge, this is one of the first studies to concurrently evaluate speaker gender equity with conference quality.

Our study offers several strengths. This study took a pragmatic approach to understanding how processes can impact gender equity, and we were able to take advantage of the evolution of the open call system (ie workshops which have been an open call process for the duration of the study versus speaking opportunities that were not).

Our study also has several limitations. First, this study is retrospective in nature and thus other processes could have contributed to the improved gender equity, such as an organization’s priorities over time. During this study period, the SHM conference saw an average 3% increase annually in women speakers and an increase of 8% from 2018 to 2019 for all speakers compared to national trends of approximately 1%,6 which suggests that the open call processes in place could be contributing to the overall increases seen. Similarly, because of the retrospective nature of the study, we cannot be certain that the improvements in conference scores were directly the result of improved gender equity, although it does suggest that the improvements in gender equity did not have an adverse impact on the scores. We also did not assess how the composition of selection committee members for the meeting could have impacted the overall composition of the speakers. Our study looked at diversity only from the perspective of gender in a binary fashion, and thus additional studies are needed to assess how to improve diversity overall. It is unclear how this new open call for speakers affects race and ethnic diversity specifically. Identifying gender for the purposes of this study was facilitated by speakers providing their own biographies and the respective pronouns used in those biographies, and thus gender was easier to ascertain than race and ethnicity, which are not as readily available. For organizations to understand their diversity, equity, and inclusion efforts, enhancing the ability to fairly track and measure diversity will be key. Lastly, understanding of the exact composition of hospitalists from both a gender and race/ethnicity perspective is lacking. Studies have suggested that, based upon those surveyed or studied, there is a fairly equal balance of men and women albeit in academic groups.3

 

 

CONCLUSIONS

An open call approach to speakers at a national hospitalist conference seems to have contributed to improvements regarding gender equity in speaking opportunities with a concurrent improvement in overall rating of the conference. The open call system is a potential mechanism that other institutions and organizations could employ to enhance their diversity efforts.

Acknowledgments

Society of Hospital Medicine Diversity, Equity, Inclusion Special Interest Group

Work Group for SPEAK UP: Marisha Burden, MD, Daniel Cabrera, MD, Amira del Pino-Jones, MD, Areeba Kara, MD, Angela Keniston, MSPH, Keshav Khanijow, MD, Flora Kisuule, MD, Chiara Mandel, Benji Mathews, MD, David Paje, MD, Stephan Papp, MD, Snehal Patel, MD, Suchita Shah Sata, MD, Dustin Smith, MD, Kevin Vuernick

Persistent gender disparities exist in pay,1,2 leadership opportunities,3,4 promotion,5 and speaking opportunities.6 While the gender distribution of the hospitalist workforce may be approaching parity,3,7,8 gender differences in leadership, speakership, and authorship have already been noted in hospital medicine.3 Between 2006 and 2012, women constituted less than a third (26%) of the presenters at the national conferences of the Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM).3

The SHM Annual Meeting has historically had an “open call” peer review process for workshop presenters with the goal of increasing the diversity of presenters. In 2019, this process was expanded to include didactic speakers. Our aim in this study was to assess whether these open call procedures resulted in improved representation of women speakers and how the proportion of women speakers affects the overall evaluation scores of the conference. Our hypothesis was that the introduction of an open call process for the SHM conference didactic speakers would be associated with an increased proportion of women speakers, compared with the closed call processes, without a negative impact on conference scores.

METHODS

The study is a retrospective evaluation of data collected regarding speakers at the annual SHM conference from 2015 to 2019. The SHM national conference typically has two main types of offerings: workshops and didactics. Workshop presenters from 2015 to 2019 were selected via an open call process as defined below. Didactic speakers (except for plenary speakers) were selected using the open call process for 2019 only.

We aimed to compare (1) the number and proportion of women speakers, compared with men speakers, over time and (2) the proportion of women speakers when open call processes were utilized versus that seen with closed call processes. Open call included workshops for all years and didactics for 2019; closed call included didactics for 2015 to 2018 and plenary sessions 2015 to 2019 (Table). The speaker list for the conferences was obtained from conference pamphlets or agendas available via Internet searches or obtained through attendance at the conference.

Speaker Categories and Identification Process

We determined whether each individual was a featured speaker (one whose talk was unopposed by other sessions), plenary speaker (defined as such in the conference pamphlets), whether they spoke in a group format, and whether the speaking opportunity type was a workshop or a didactic session. Numbers of featured and plenary speakers were combined because of low numbers. SHM provided deidentified conference evaluation data for each year studied. For the purposes of this study, we analyzed all speakers which included physicians, advanced practice providers, and professionals such as nurses and other interdisciplinary team members. The same speaker could be included multiple times if they had multiple speaking opportunities.

 

 

Open Call Process

We defined the “open call process” (referred to as “open call” here forward) as the process utilized by SHM that includes the following two components: (1) advertisements to members of SHM and to the medical community at large through a variety of mechanisms including emails, websites, and social media outlets and (2) an online submission process that includes names of proposed speakers and their topic and, in the case of workshops, session objectives as well as an outline of the proposed workshop. SHM committees may also submit suggestions for topics and speakers. Annual Conference Committee members then review and rate submissions on the categories of topic, organization and clarity, objectives, and speaker qualifications (with a focus on institutional, geographic, and gender diversity). Scores are assigned from 1 to 5 (with 5 being the best score) for each category and a section for comments is available. All submissions are also evaluated by the course director.

After initial committee reviews, scores with marked reviewer discrepancies are rereviewed and discussed by the committee and course director. A cutoff score is then calculated with proposals falling below the cutoff threshold omitted from further consideration. Weekly calls are then focused on subcategories (ie tracks) with emphasis on clinical and educational content. Each of the tracks have a subcommittee with track leads to curate the best content first and then focus on final speaker selection. More recently, templates are shared with the track leads that include a location to call out gender and institutional diversity. Weekly calls are held to hone the content and determine the speakers.

For the purposes of this study, when the above process was not used, the authors refer to it as “closed call.” Closed call processes do not typically involve open invitations or a peer review process. (Table)

Gender

Gender was assigned based on the speaker’s self-identification by the pronouns used in their biography submitted to the conference or on their institutional website or other websites where the speaker was referenced. Persons using she/her/hers pronouns were noted as women and persons using he/him/his were noted as men. For the purposes of this study, we conceptualized gender as binary (ie woman/man) given the limited information we had from online sources.

ANALYSIS

REDCap, a secure, Web-based application for building and managing online survey and databases, was used to collect and manage all study data.9

All analyses were performed using SAS Enterprise Guide 8.1 (SAS Institute, Inc., Cary, North Carolina) using retrospectively collected data. A Cochran-Armitage test for trend was used to evaluate the proportion of women speakers from 2015 to 2019. A chi-square test was used to assess the proportion of women speakers for open call processes versus that seen with closed call. One-way analysis of variance (ANOVA) was used to evaluate annual conference evaluation scores from 2015 to 2019. Either numbers with proportions or means with standard deviations have been reported. Bonferroni’s correction for multiple comparisons was applied, with a P < .008 considered statistically significant.

 

 

RESULTS

Between 2015 and 2019, a total of 709 workshop and didactic presentations were given by 1,261 speakers at the annual Society of Hospital Medicine Conference. Of these, 505 (40%) were women; 756 (60%) were men. There were no missing data.

From 2015 to 2019, representation of women speakers increased from 35% of all speakers to 47% of all speakers (P = .0068). Women plenary speakers increased from 23% in 2015 to 45% in 2019 (P = .0396).

The proportion of women presenters for workshops (which have utilized an open call process throughout the study period), ranged from 43% to 53% from 2015 to 2019 with no statistically significant difference in gender distribution across years (Figure).



A greater proportion of speakers selected by an open call process were women compared to when speakers were selected by a closed call process (261 (47%) vs 244 (34%); P < .0001).

Of didactics or workshops given in a group format (N = 299), 82 (27%) were given by all-men groups and 38 (13%) were given by all-women groups. Women speakers participating in all-women group talks accounted for 21% of all women speakers; whereas men speakers participating in all-men group talks account for 26% of all men speakers (P = .02). We found that all-men group speaking opportunities did decrease from 41% of group talks in 2015 to 21% of group talks in 2019 (P = .0065).

We saw an average 3% annual increase in women speakers from 2015 to 2019, an 8% increase from 2018 to 2019 for all speakers, and an 11% increase in women speakers specific to didactic sessions. Overall conference ratings increased from a mean of 4.3 ± 0.24 in 2015 to a mean of 4.6 ± 0.14 in 2019 (n = 1,202; P < .0001; Figure).

DISCUSSION

The important findings of this study are that there has been an increase in women speakers over the last 5 years at the annual Society of Hospital Medicine Conference, that women had higher representation as speakers when open call processes were followed, and that conference scores continued to improve during the time frame studied. These findings suggest that a systematic open call process helps to support equitable speaking opportunities for men and women at a national hospital medicine conference without a negative impact on conference quality.

To recruit more diverse speakers, open call and peer review processes were used in addition to deliberate efforts at ensuring diversity in speakers. We found that over time, the proportion of women with speaking opportunities increased from 2015 to 2019. Interestingly, workshops, which had open call processes in place for the duration of the study period, had almost equal numbers of men and women presenting in all years. We also found that the number of all-men speaking groups decreased between 2015 and 2019.

A single process change can impact gender equity, but the target of true equity is expected to require additional measures such as assessment of committee structures and diversity, checklists, and reporting structures (data analysis and plans when goals not achieved).10-13 For instance, the American Society for Microbiology General Meeting was able to achieve gender equity in speakers by a multifold approach including ensuring the program committee was aware of gender statistics, increasing female representation among session convener teams, and direct instruction to try to avoid all-male sessions.11

It is important to acknowledge that these processes do require valuable resources including time. SHM has historically used committee volunteers to conduct the peer review process with each committee member reviewing 20 to 30 workshop submissions and 30 to 50 didactic sessions. While open processes with peer review seem to generate improved gender equity, ensuring processes are in place during the selection process is also key.

Several recent notable efforts to enhance gender equity and to increase diversity have been proposed. One such example of a process that may further improve gender equity was proposed by editors at the Journal of Hospital Medicine to assess current representation via demographics including gender, race, and ethnicity of authors with plans to assess patterns in the coming years.14 The American College of Physicians also published a position paper on achieving gender equity with a recommendation that organizational policies and procedures should be implemented that address implicit bias.15

Our study showed that, from 2015 to 2019, conference evaluations saw a significant increase in the score concurrently with the rise in proportion of women speakers. This finding suggests that quality does not seem to be affected by this new methodology for speaker selection and in fact this methodology may actually help improve the overall quality of the conference. To our knowledge, this is one of the first studies to concurrently evaluate speaker gender equity with conference quality.

Our study offers several strengths. This study took a pragmatic approach to understanding how processes can impact gender equity, and we were able to take advantage of the evolution of the open call system (ie workshops which have been an open call process for the duration of the study versus speaking opportunities that were not).

Our study also has several limitations. First, this study is retrospective in nature and thus other processes could have contributed to the improved gender equity, such as an organization’s priorities over time. During this study period, the SHM conference saw an average 3% increase annually in women speakers and an increase of 8% from 2018 to 2019 for all speakers compared to national trends of approximately 1%,6 which suggests that the open call processes in place could be contributing to the overall increases seen. Similarly, because of the retrospective nature of the study, we cannot be certain that the improvements in conference scores were directly the result of improved gender equity, although it does suggest that the improvements in gender equity did not have an adverse impact on the scores. We also did not assess how the composition of selection committee members for the meeting could have impacted the overall composition of the speakers. Our study looked at diversity only from the perspective of gender in a binary fashion, and thus additional studies are needed to assess how to improve diversity overall. It is unclear how this new open call for speakers affects race and ethnic diversity specifically. Identifying gender for the purposes of this study was facilitated by speakers providing their own biographies and the respective pronouns used in those biographies, and thus gender was easier to ascertain than race and ethnicity, which are not as readily available. For organizations to understand their diversity, equity, and inclusion efforts, enhancing the ability to fairly track and measure diversity will be key. Lastly, understanding of the exact composition of hospitalists from both a gender and race/ethnicity perspective is lacking. Studies have suggested that, based upon those surveyed or studied, there is a fairly equal balance of men and women albeit in academic groups.3

 

 

CONCLUSIONS

An open call approach to speakers at a national hospitalist conference seems to have contributed to improvements regarding gender equity in speaking opportunities with a concurrent improvement in overall rating of the conference. The open call system is a potential mechanism that other institutions and organizations could employ to enhance their diversity efforts.

Acknowledgments

Society of Hospital Medicine Diversity, Equity, Inclusion Special Interest Group

Work Group for SPEAK UP: Marisha Burden, MD, Daniel Cabrera, MD, Amira del Pino-Jones, MD, Areeba Kara, MD, Angela Keniston, MSPH, Keshav Khanijow, MD, Flora Kisuule, MD, Chiara Mandel, Benji Mathews, MD, David Paje, MD, Stephan Papp, MD, Snehal Patel, MD, Suchita Shah Sata, MD, Dustin Smith, MD, Kevin Vuernick

References

1. Weaver AC, Wetterneck TB, Whelan CT, Hinami K. A matter of priorities? Exploring the persistent gender pay gap in hospital medicine. J Hosp Med. 2015;10(8):486-490. https://doi.org/10.1002/jhm.2400.
2. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. https://doi.org/10.1001/jamainternmed.2016.3284.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med. 2015;10(8):481-485. https://doi.org/10.1002/jhm.2340.
4. Silver JK, Ghalib R, Poorman JA, et al. Analysis of gender equity in leadership of physician-focused medical specialty societies, 2008-2017. JAMA Intern Med. 2019;179(3):433-435. https://doi.org/10.1001/jamainternmed.2018.5303.
5. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA. 2015;314(11):1149-1158. https://doi.org/10.1001/jama.2015.10680.
6. Ruzycki SM, Fletcher S, Earp M, Bharwani A, Lithgow KC. Trends in the Proportion of Female Speakers at Medical Conferences in the United States and in Canada, 2007 to 2017. JAMA Netw Open. 2019;2(4):e192103. https://doi.org/10.1001/jamanetworkopen.2019.2103
7. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27. https://doi.org/10.1007/s11606-011-1892-5.
8. Today’s Hospitalist 2018 Compensation and Career Survey Results. https://www.todayshospitalist.com/salary-survey-results/. Accessed September 28, 2019.
9. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. https://doi.org/10.1016/j.jbi.2008.08.010.
10. Burden M, del Pino-Jones A, Shafer M, Sheth S, Rexrode K. Association of American Medical Colleagues (AAMC) Group on Women in Medicine and Science. Recruitment Toolkit: https://www.aamc.org/download/492864/data/equityinrecruitmenttoolkit.pdf. Accessed July 27, 2019.
11. Casadevall A. Achieving speaker gender equity at the american society for microbiology general meeting. MBio. 2015;6:e01146. https://doi.org/10.1128/mBio.01146-15.
12. Westring A, McDonald JM, Carr P, Grisso JA. An integrated framework for gender equity in academic medicine. Acad Med. 2016;91(8):1041-1044. https://doi.org/10.1097/ACM.0000000000001275.
13. Martin JL. Ten simple rules to achieve conference speaker gender balance. PLoS Comput Biol. 2014;10(11):e1003903. https://doi.org/10.1371/journal.pcbi.1003903.
14. Shah SS, Shaughnessy EE, Spector ND. Leading by example: how medical journals can improve representation in academic medicine. J Hosp Med. 2019;14(7):393. https://doi.org/10.12788/jhm.3247.
15. Butkus R, Serchen J, Moyer DV, et al. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med. 2018;168:721-723. https://doi.org/10.7326/M17-3438.

References

1. Weaver AC, Wetterneck TB, Whelan CT, Hinami K. A matter of priorities? Exploring the persistent gender pay gap in hospital medicine. J Hosp Med. 2015;10(8):486-490. https://doi.org/10.1002/jhm.2400.
2. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. https://doi.org/10.1001/jamainternmed.2016.3284.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med. 2015;10(8):481-485. https://doi.org/10.1002/jhm.2340.
4. Silver JK, Ghalib R, Poorman JA, et al. Analysis of gender equity in leadership of physician-focused medical specialty societies, 2008-2017. JAMA Intern Med. 2019;179(3):433-435. https://doi.org/10.1001/jamainternmed.2018.5303.
5. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA. 2015;314(11):1149-1158. https://doi.org/10.1001/jama.2015.10680.
6. Ruzycki SM, Fletcher S, Earp M, Bharwani A, Lithgow KC. Trends in the Proportion of Female Speakers at Medical Conferences in the United States and in Canada, 2007 to 2017. JAMA Netw Open. 2019;2(4):e192103. https://doi.org/10.1001/jamanetworkopen.2019.2103
7. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27. https://doi.org/10.1007/s11606-011-1892-5.
8. Today’s Hospitalist 2018 Compensation and Career Survey Results. https://www.todayshospitalist.com/salary-survey-results/. Accessed September 28, 2019.
9. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. https://doi.org/10.1016/j.jbi.2008.08.010.
10. Burden M, del Pino-Jones A, Shafer M, Sheth S, Rexrode K. Association of American Medical Colleagues (AAMC) Group on Women in Medicine and Science. Recruitment Toolkit: https://www.aamc.org/download/492864/data/equityinrecruitmenttoolkit.pdf. Accessed July 27, 2019.
11. Casadevall A. Achieving speaker gender equity at the american society for microbiology general meeting. MBio. 2015;6:e01146. https://doi.org/10.1128/mBio.01146-15.
12. Westring A, McDonald JM, Carr P, Grisso JA. An integrated framework for gender equity in academic medicine. Acad Med. 2016;91(8):1041-1044. https://doi.org/10.1097/ACM.0000000000001275.
13. Martin JL. Ten simple rules to achieve conference speaker gender balance. PLoS Comput Biol. 2014;10(11):e1003903. https://doi.org/10.1371/journal.pcbi.1003903.
14. Shah SS, Shaughnessy EE, Spector ND. Leading by example: how medical journals can improve representation in academic medicine. J Hosp Med. 2019;14(7):393. https://doi.org/10.12788/jhm.3247.
15. Butkus R, Serchen J, Moyer DV, et al. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med. 2018;168:721-723. https://doi.org/10.7326/M17-3438.

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Inpatient Management of Diabetic Foot Infections: A Review of the Guidelines for Hospitalists

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Diabetic foot infection (DFI) is a common result of diabetes and represents the most frequent complication requiring hospitalization and lower extremity amputation.1,2 Hospital discharges related to diabetic lower extremity ulcers increased from 72,000 in 1988 to 113,000 in 2007,3 and admissions related to infection rose 30% between 2005 and 2010.2 Ulceration and amputation are associated with a 40% to 50% 5-year mortality rate.4,5

Aggressive risk-factor management and interprofessional care can significantly reduce major amputations and mortality.6-13 Consistent and high-quality care for patients admitted with DFI is essential for optimizing outcomes; however, management varies widely, and critical assessment and prevention measures are often not employed by providers.14 This review synthesizes recommendations from existing guidelines to provide an overview of the best practices for the diagnosis, management, and discharge of DFI in the hospital setting (Supplementary Table 1, Supplementary Figure).

DETECTION AND STAGING OF INFECTION

The first step in the management of a DFI is a careful assessment of the presence and depth of infection.15 The Infectious Diseases Society of America (IDSA) guidelines recommend using at least 2 signs of classic inflammation (erythema, warmth, swelling, tenderness, or pain) or purulent drainage to diagnose soft tissue infection.1,15,16 Patients with ischemia may present atypically, with nonpurulent secretions, friable or discolored granulation tissue, undermining of wound edges, and foul odor. 1,15,16 Additional risk factors for DFI include ulceration for more than 30 days, recurrent foot ulcers, a traumatic foot wound, severe peripheral arterial disease (PAD) in the affected limb (ankle brachial index [ABI] <0.4), prior lower extremity amputation, loss of protective sensation, end-stage renal disease, and a history of walking barefoot.15,17,18

Appropriate classification of wound severity is critical in determining the need for hospitalization, antibiotic selection, surgical intervention, and prognosis. Multiple staging systems that incorporate physical examination findings, markers of systemic inflammation, and ischemia15,19,20 have been proposed. The Perfusion, Extent, Depth, Infection, and Sensation (PEDIS) grade was developed as a research tool and incorporates infection, ischemia, neuropathy, wound size, and systemic inflammation.15 The International Working Group on the Diabetic Foot (IWGDF) and the IDSA recommend use of the full or simplified PEDIS score in clinical practice (the IWGDF/IDSA Classification, Table 1) because these classifications predicted hospitalization and lower extremity amputation in prospective studies, with amputation rates of 3% for uninfected ulcers and up to 70% for severe infection.1,15 Patients with PEDIS grade 4 infections also have an increased mean length of stay compared with patients with grade 3 infections.21,22

CRITERIA FOR HOSPITALIZATION

In practice, the decision to admit is based on clinical and systems-based drivers (Supplementary Table 2). The IDSA and IWGDF guidelines recommend hospitalization for patients with severe (PEDIS grade 4) infection, moderate (PEDIS grade 3) infection with certain complications (eg, severe PAD or lack of home support), an inability to comply with required outpatient treatment, lack of improvement with outpatient therapy, or presence of metabolic or hemodynamic instability.1,15 Clinicians must also consider the need for surgical debridement or complex antibiotic choices due to allergies and comorbidities. Hospitalists may also consider admission in cases in which outpatient follow-up cannot be easily arranged (eg, uninsured patients).

Outpatient management may be appropriate for patients with mild infections who are willing to be reassessed within 72 hours, or sooner if the infection worsens.23 For patients with moderate infections (eg, osteomyelitis without systemic signs of infection), access to an outpatient interprofessional DFI care team can potentially decrease the need for admission.

DIAGNOSIS OF OSTEOMYELITIS

Clinical features that raise suspicion for osteomyelitis include ulceration for at least 6 weeks with appropriate wound care and offloading, wound extension to the bone or joint, exposed bone, ulcers larger than 2 cm2, previous history of a wound, multiple wounds, and appearance of a sausage digit.15

The gold standard for diagnosis of osteomyelitis is a bone biopsy with histology. In the absence of histology, physicians rely on physical examination, inflammatory markers, and imaging to make the diagnosis. The presence of visible, chronically exposed bone within a forefoot ulcer is diagnostic. The accuracy of a probe to bone test depends on the pretest probability of osteomyelitis. Sensitivity and specificity range from 60% to 87% and from 85% to 91%, respectively.24 For patients with a single forefoot ulcer and PEDIS grade 2 or 3 infection, considering both ulcer depth and serum inflammatory markers (ulcer depth greater than 3 mm, or C-reactive protein greater than 3.2 mg/dL; ulcer depth greater than 3 mm, or erythrocyte sedimentation rate greater than 60 mm/h) increases sensitivity to 100%, although the specificity is relatively low (55% and 60%, respectively).25 When the diagnosis remains uncertain by physical examination, imaging is necessary for further evaluation.

ROLE OF IMAGING

All patients with DFI should have plain radiographs to look for foot deformities, soft tissue gas, foreign bodies, and osteomyelitis. If plain radiographs show classic evidence of osteomyelitis, (ie, cortical erosion, periosteal reaction, mixed lucency, and sclerosis in the absence of neuro-osteoarthropathy), advanced imaging is not necessary. However, these changes may not appear on plain films for up to 1 month after infection onset.15,26

The purpose of advanced imaging in the inpatient management of DFI is to detect conditions not obvious by physical examination or by plain radiographs that would alter surgical management (ie, deep abscess or necrotic bone) or antibiotic duration (ie, osteomyelitis or tenosynovitis).15 Magnetic resonance imaging (MRI) is the diagnostic modality of choice when the wound does not probe to bone and the diagnosis remains uncertain27 due to its accuracy and availability.1,15 However, MRI cannot always distinguish between infection and neuro-osteoarthropathy, especially in patients who have infection superimposed on a Charcot foot, have had recent surgical intervention, or have osteosynthesis material at the infection site.24 If MRI is contraindicated, guidelines vary on the next recommended test. The IDSA and the Society for Vascular Surgery recommend a labeled white blood cell scan combined with a bone scan, whereas the IWGDF recommends a labeled leukocyte scan, a single photon emission computed tomography (SPECT/CT), or a fluorodeoxyglucose positron emission tomography (FDG PET) scan.1,15,19 A recent comparison of a labeled white blood cell SPECT/CT versus MRI (using histology as the gold standard) reported that SPECT/CT had a similar sensitivity (89% versus 87%, respectively) and specificity (35% versus 37%, respectively) to MRI.28 In practice, physicians should consider which studies are readily available and confidently interpreted by radiologists at their institution.

ASSESSMENT OF ULCER ETIOLOGY

After infection is diagnosed and staged, clinicians should determine the underlying derangement in order to prevent recurrence after discharge. Common derangements leading to ulceration in diabetics include PAD, neuropathy, muscular tension, altered foot mechanics, trauma, or a combination of the above.1,15,29-31 All patients with DFI should undergo pedal perfusion assessment by an ABI, ankle and pedal Doppler arterial waveforms, and either toe brachial index (TBI) or transcutaneous oxygen pressure.1,15,19 In cases of suspected calcification, TBI is a more reliable measure of ischemia compared with the ABI.16,19 For patients with signs and symptoms of ischemia and an abnormal ABI or TBI measurement (ABI <0.9 and TBI <0.7), a nonurgent consultation with a vascular surgeon is recommended, while patients with severe ischemia (ABI <0.4) usually require urgent revascularization.15,32

A sensory examination with a Semmes-Weinstein monofilament should be conducted to identify patients with loss of protective sensation who may benefit from offloading devices and custom orthotics.15 Foot anatomy and mechanics as well as potential Achilles tendon contractures should be evaluated by a foot specialist such as a podiatrist, orthotist, orthopedist, or vascular surgeon, especially if debridement or amputation is being contemplated.

OBTAINING CULTURES

After diagnosing the infection clinically, appropriately obtained cultures are essential to guide therapy in all except mild cases with no prior antibiotic exposure or MRSA risk.1,15 Guidelines strongly recommend that specimens be obtained by biopsy or curettage from deep tissue at the base of the ulcer after the wound has been cleansed and debrided and prior to initiating antibiotics.1,15,33 Aspiration of purulent secretions using a sterile needle and syringe is another acceptable culturing method.15 While convenient, swab cultures are prone to both false-positive and false-negative results.34 Repeat cultures are only needed for patients who are not responding to treatment or for surveillance of resistant organisms.1

In cases of osteomyelitis, bone specimens should be sent for culture and histology either during surgical debridement or a bone biopsy. At the time of debridement, cultures and pathology should be sent from the proximal (clean) bone margin in order to document whether there is residual osteomyelitis postdebridement.35 For patients not planned for debridement, a bone biopsy is recommended if the diagnosis of osteomyelitis is unclear, response to empiric therapy is poor, broad-spectrum antibiotics are being considered, or the infection is in the midfoot or hindfoot.1,15,19 Results from soft tissue or sinus tract specimens should not be used to guide antibiotic selection in osteomyelitis, as several studies suggest that they do not correlate with bone culture results; one retrospective review found a mere 22.5% correlation between wound swabs and bone biopsy.1,36 A 2-week antibiotic-free period prior to biopsy is recommended in order to minimize the risk of false-negative results but must be balanced with the risk of worsening infection.1,15 If possible, the biopsy should be performed through uninfected tissue under fluoroscopy or CT guidance, with 2 to 3 cores obtained for culture and histology.1,15

INTERPROFESSIONAL INPATIENT CARE

A growing number of health systems have created inpatient and/or outpatient interprofessional diabetic foot care teams, and several studies demonstrated an association between these teams and a reduction in major amputations.7-11,13 The goal of the inpatient team is to rapidly triage patients with moderate to severe infections, expedite surgical interventions and culture collection, establish an effective treatment plan, and ensure adherence postdischarge to optimize outcomes. The common core of most teams includes podiatry, endocrinology, wound care, and vascular surgery, but team composition may vary based on the availability of local specialists with interest and expertise in DFI.9,10,33

The division of consultation between podiatry and orthopedic surgery is highly dependent upon individual practice patterns and hospital structure. In general, forefoot ulcers may be managed by podiatry or orthopedic surgery, while severe Charcot deformities are most often treated by orthopedic surgeons. Wound care nurses are often integral to successful wound healing, collaborating across specialties and serving as a weekly or biweekly point of contact for patients.

Early involvement of Infectious Disease (ID) specialists can be useful for guiding antibiotic choices and facilitating follow-up. ID should be involved with patients who require long-term antibiotic therapy (ie, cases of deep-tissue infection that are not completely amputated or debrided), have failed outpatient or empiric therapy, have antibiotic allergies or drug-resistant pathogens, or are being considered for outpatient parenteral antibiotic therapy.

ANTIBIOTIC THERAPY

Empiric antibiotic therapy should be based on infection severity and the likely causative agent (Figure). Mild cases are managed with oral agents that target Staphylococcus aureus and Streptococcus species such as cephalexin or clindamycin.1,15 Antibiotics for moderate (PEDIS grade 3) infections can be oral or parenteral (eg, ampicillin-sulbactam or ertapenem) and should include coverage for the above pathogens in addition to Enterobacteriaciae and anaerobes.1,15 Empiric anti-MRSA coverage is optional in mild to moderate infections and should be reserved for patients with known risk factors, such as prior colonization, recent hospitalization, residence in a chronic care facility, previous amputation, or a high local prevalence of MRSA (50% MRSA prevalence for mild infections or 30% prevalence for moderate infections). 1,15Fluoroquinolones are no longer effective against S. aureus in most of the United States and should not be used as monotherapy if MRSA is suspected.37,38 A recent retrospective observational study found that ceftaroline fosamil treatment of DFI was associated with an 81% success rate, including for patients with comorbidities, MRSA, mixed infections, or surgical intervention, but it has not yet been studied in a comparative trial.39 Antipseudomonal therapy is not necessary in most moderate cases and should be reserved for patients who have severe infections (PEDIS grade 4) or specific risk-factors for Pseudomonas.1,15 Severe infections, gangrenous wounds, or necrotizing infections require parenteral agents to cover MRSA (ie, vancomycin or daptomycin), Pseudomonas (ie, cefepime or piperacillin-tazobactam), and anaerobes. 1,15 Anaerobic coverage must be added to cefepime but is not necessary with piperacillin-tazobactam or meropenem.40 Definitive therapy should be based on culture results, sensitivity testing, and the patient’s clinical response to the empiric regimen.15

The duration of antibiotic treatment for DFI is based on the severity of infection and response to treatment (Supplementary Table 3). Treatment should continue until the signs and symptoms of infection resolve, but there is no strong evidence to support treatment through complete healing. Healing will usually occur in 1 to 2 weeks for mild infections and in 2 to 3 weeks for moderate or severe infections. However, prescribing antibiotics for a fixed duration is not recommended and can result in an inadequate or unnecessarily prolonged course, with the potential for increased costs, adverse events, and antibiotic resistance.1,15,16 Therapy may be shortened by debridement, resection, or amputation, or lengthened in patients who are immunocompromised; have deep, large, necrotic, or poorly perfused wounds; do not undergo resection; or have an implanted foreign body at the infection site.1 If the patient does not improve despite targeted antibiotic treatment, providers should assess the need to revascularize, repeat debridement for new cultures, resect any progression of infection, or modify the antibiotic regimen to maximize tissue penetration and minimize drug interactions.1

Traditional management of diabetic foot osteomyelitis has relied almost exclusively on resection of all infected bone. However, data have emerged over the last 10 years to support initial medical management of select patients. Further research regarding the optimal treatment regimen and duration is ongoing, with 1 recent, randomized control trial comparing 6 versus 12 weeks of antibiotics for patients treated medically for osteomyelitis finding no difference in remission rates.1,41 Patients managed surgically for osteomyelitis are often treated parenterally for at least 4 weeks, but this practice is not based on strong evidence, and guidelines suggest most patients could be switched to highly bioavailable oral agents after a shorter course of intravenous therapy.1,15 Guidelines recommend 2 to 5 days of antibiotics after complete resection of infected bone and soft tissue (Supplementary Table 3). If the infected soft tissue remains, 1 to 3 weeks of therapy is usually sufficient, while 4 to 6 weeks is often needed if there is residually infected but viable bone.15

SURGICAL MANAGEMENT

Inpatient providers should be familiar with the indications for surgery in DFI patients in order to effectively utilize surgical consultants and ensure critical procedures are completed prior to discharge. Surgical consultation, preferably with a surgeon skilled in foot preservation, is recommended for patients with moderate or severe infections.1,15,33 Surgical indications include abscess, necrosis, compartment syndrome, refractory sepsis despite antibiotics, and extensive bone or joint destruction underlying the open wound, as well as other conditions listed in Table 2. While debridement often aids wound healing, it should be avoided in cases with dry eschar, especially when ischemia is present, as the infection will usually resolve with autoamputation.1,42,43

In patients with osteomyelitis, the decision between medical and surgical management is complex. Absolute indications for surgical resection include systemic toxicity with associated tissue infection, an open or infected joint space, and patients with prosthetic heart valves.27 However, the need for surgery is unclear beyond these absolute indications, and approximately two-thirds of osteomyelitis cases may be arrested or cured with antibiotic therapy alone.1 A prospective randomized comparative trial of patients with diabetic foot osteomyelitis found that patients treated with 90 days of antibiotics had similar healing rates, times to healing, and short-term complications as compared with those who underwent conservative bone resection.44 While further research is needed to determine which types of patients with osteomyelitis may be successfully treated without surgery, the IWGDF, the IDSA, and osteomyelitis experts have offered guidance on this decision (Table 2).1,15,27 If resection is necessary, hospitalists should request at least 4 specimens to help guide postoperative antibiotic therapy (1 sample for histology and 1 for microbiology, at both the grossly abnormal bone and the bone margin), as negative margin cultures predict a lower relapse risk for infection.1,35

Every effort should be made to preserve the limb, and urgent amputation is rarely needed except in cases with extensive necrosis or life-threatening infection. Elective amputation may be considered for patients who have recurrent ulceration or irreversible loss of foot function or who would require an excessively prolonged or intensive hospital stay.15 All patients with plantar ulcers that are unresponsive to conservative management and limited ankle dorsiflexion should be evaluated for pressure-relieving surgeries, such as Achilles lengthening and gastrocnemius recession.45,46 Studies suggest that pressure-relieving surgeries can increase rates of ulcer healing from 88% to 100% when added to total contact casting.47

CRITERIA FOR DISCHARGE

Guidelines suggest that patients be clinically stable before discharge, complete any urgent surgery, achieve acceptable glycemic control, and be presented with a comprehensive outpatient plan, including antibiotic therapy, offloading, wound care instructions, and outpatient follow-up (Supplementary Table 4). Physicians must consider patient and family preferences, expected adherence to therapy, availability of home support, and payer and cost issues when creating the discharge plan.15

INTERPROFESSIONAL OUTPATIENT CARE

An effective outpatient care team is critical to ensure wound healing and infection resolution. Efforts should be made to discharge patients to a comprehensive outpatient interprofessional foot care team, with a plan that includes professional foot care, patient education, and adequate footwear.48 Team composition varies but often includes representatives from vascular surgery, podiatry, orthotics, wound care, endocrinology, orthopedics, physical therapy and rehabilitation, infectious disease, and dermatology.11-13Interprofessional outpatient clinics can ease the burden of transportation and shorten the time to needed interventions in the case of treatment failure. Follow-up appointments within 1 to 2 weeks postdischarge have been found to reduce the risk of readmission in other high-risk conditions, and this is a reasonable time frame for DFI as well.49

CONCLUSION

DFIs are a common cause of morbidity in patients with diabetes and result in significant costs to the US healthcare system. Hospitalized patients with a DFI require appropriate classification of wound severity and assessment of vascular status, protective sensation, and potential osteomyelitis. Inpatient management of these patients includes obtaining necessary cultures, choosing an antibiotic regimen based on infection severity and the likely causative agent, and evaluating the need for surgical intervention. Prior to discharge, providers should determine a comprehensive follow-up plan and ensure patient engagement. Finally, interprofessional management has been shown to improve outcomes in DFI and should be adopted in both the inpatient and outpatient settings.

Disclosure

The authors report no conflicts of interest.

References

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3. Number (in thousands) of hospital discharges with peripheral arterial disease (PAD), ulcer/inflammation/infection (ULCER), or neuropathy as first-listed diagnosis and diabetes as any-listed diagnosis United States, 1988-2007. Centers for Disease Control and Prevention website. http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig1_number.htm. Updated 2014. Accessed September 23, 2016.
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11. Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: A prospective study. Diabetes Care. 1999;22(9):1428-1431. PubMed
12. Driver VR, Goodman RA, Fabbi M, French MA, Andersen CA. The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. J Am Podiatr Med Assoc. 2010;100(4):235-241. PubMed
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14. Prompers L, Huijberts M, Apelqvist J, et al. Delivery of care to diabetic patients with foot ulcers in daily practice: Results of the Eurodiale study, a prospective cohort study. Diabet Med. 2008;25(6):700-707. PubMed
15. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173. PubMed
16. Noor S, Khan RU, Ahmad J. Understanding diabetic foot infection and its management. Diabetes Metab Syndr. 2016;11(2):149-156. PubMed
17. Hill MN, Feldman HI, Hilton SC, Holechek MJ, Ylitalo M, Benedict GW. Risk of foot complications in long-term diabetic patients with and without ESRD: A preliminary study. ANNA J. 1996;23(4):381-386; discussion 387-388. PubMed
18. Mohler ER, III. Peripheral arterial disease: Identification and implications. Arch Intern Med. 2003;163(19):2306-2314PubMed
19. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63(2 Suppl):3S-21S. PubMed
20. Noor S, Zubair M, Ahmad J. Diabetic foot ulcer--A review on pathophysiology, classification and microbial etiology. Diabetes Metab Syndr. 2015;9(3):192-199. PubMed
21. Wukich DK, Hobizal KB, Brooks MM. Severity of diabetic foot infection and rate of limb salvage. Foot Ankle Int. 2013;34(3):351-358. PubMed
22. Wukich DK, Hobizal KB, Raspovic KM, Rosario BL. SIRS is valid in discriminating between severe and moderate diabetic foot infections. Diabetes Care. 2013;36(11):3706-3711PubMed
23. Grigoropoulou P, Eleftheriadou I, Jude EB, Tentolouris N. Diabetic foot infections: An update in diagnosis and management. Curr Diab Rep. 2017;17(1):3. PubMed
24. Glaudemans AW, Uçkay I, Lipsky BA. Challenges in diagnosing infection in the diabetic foot. Diabet Med. 2015;32(6):748-759. PubMed
25. Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. J Foot Ankle Surg. 2009;48(1):39-46. PubMed
26. Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis. 2004;39 Suppl 2:S115-S122. PubMed
27. Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle. 2016;7:30079. PubMed
28. La Fontaine J, Bhavan K, Lam K, et al. Comparison between Tc-99m WBC SPECT/CT and MRI for the diagnosis of biopsy-proven diabetic foot osteomyelitis. Wounds. 2016;28(8):271-278. PubMed
29. Bembi V, Singh S, Singh P, Aneja GK, Arya TV, Arora R. Prevalence of peripheral arterial disease in a cohort of diabetic patients. South Med J. 2006;99(6):564-569. PubMed
30. Marso SP, Hiatt WR. Peripheral arterial disease in patients with diabetes. J Am Coll Cardiol. 2006;47(5):921-929. PubMed
31. Hinchliffe RJ, Andros G, Apelqvist J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012;28 Suppl 1:179-217. PubMed
32. Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ. Evidence-based management of PAD & the diabetic foot. Eur J Vasc Endovasc Surg. 2013;45(6):673-681. PubMed

 

 

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34. 2016;32 Suppl 1:16-24.Diabetes Metab Res Rev48. Bus SA, van Netten JJ, Lavery LA, et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. PubMed
35. 2003;85-A(8):1436-1445.J Bone Joint Surg Am47. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. PubMed
36. 2015;21(2):77-85.Foot Ankle Surg46. Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. PubMed
37. 2016;32 Suppl 1:25-36.Diabetes Metab Res Rev45. Bus SA, Armstrong DG, van Deursen RW, et al. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. PubMed
38. 2014;37(3):789-795.Diabetes Care44. Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: A randomized comparative trial. PubMed
39. 1996;183(1):61-64.J Am Coll Surg43. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. PubMed
40. 2002;10(6):354-359.Wound Repair Regen42. Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. PubMed
41. 2015;38(2):302-307.Diabetes Care41. Tone A, Nguyen S, Devemy F, et al. Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: A multicenter open-label controlled randomized study. PubMed
42. 2014;35(10):1229-1235.Infect Control Hosp Epidemiol40. Schultz L, Lowe TJ, Srinivasan A, Neilson D, Pugliese G. Economic impact of redundant antimicrobial therapy in US hospitals. PubMed
43. 2015;31(4):395-401.Diabetes Metab Res Rev39. Lipsky BA, Cannon CM, Ramani A, et al. Ceftaroline fosamil for treatment of diabetic foot infections: the CAPTURE study experience. PubMed
2011;55(9):4154-4160.Antimicrob Agents Chemother.38. Richter SS, Heilmann KP, Dohrn CL, et al. Activity of ceftaroline and epidemiologic trends in Staphylococcus aureus isolates collected from 43 medical centers in the United States in 2009. PubMed
44. 2011;52(3):e18-e55.Clin Infect Dis37. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. PubMed
45. 2006;42(1):57-62.Clin Infect Dis36. Senneville E, Melliez H, Beltrand E, et al. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: Concordance with ulcer swab cultures. PubMed
46. 2012;51(6):749-752.J Foot Ankle Surg35. Atway S, Nerone VS, Springer KD, Woodruff DM. Rate of residual osteomyelitis after partial foot amputation in diabetic patients: A standardized method for evaluating bone margins with intraoperative culture. PubMed
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994-1000. Published online first September 20, 2017
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Diabetic foot infection (DFI) is a common result of diabetes and represents the most frequent complication requiring hospitalization and lower extremity amputation.1,2 Hospital discharges related to diabetic lower extremity ulcers increased from 72,000 in 1988 to 113,000 in 2007,3 and admissions related to infection rose 30% between 2005 and 2010.2 Ulceration and amputation are associated with a 40% to 50% 5-year mortality rate.4,5

Aggressive risk-factor management and interprofessional care can significantly reduce major amputations and mortality.6-13 Consistent and high-quality care for patients admitted with DFI is essential for optimizing outcomes; however, management varies widely, and critical assessment and prevention measures are often not employed by providers.14 This review synthesizes recommendations from existing guidelines to provide an overview of the best practices for the diagnosis, management, and discharge of DFI in the hospital setting (Supplementary Table 1, Supplementary Figure).

DETECTION AND STAGING OF INFECTION

The first step in the management of a DFI is a careful assessment of the presence and depth of infection.15 The Infectious Diseases Society of America (IDSA) guidelines recommend using at least 2 signs of classic inflammation (erythema, warmth, swelling, tenderness, or pain) or purulent drainage to diagnose soft tissue infection.1,15,16 Patients with ischemia may present atypically, with nonpurulent secretions, friable or discolored granulation tissue, undermining of wound edges, and foul odor. 1,15,16 Additional risk factors for DFI include ulceration for more than 30 days, recurrent foot ulcers, a traumatic foot wound, severe peripheral arterial disease (PAD) in the affected limb (ankle brachial index [ABI] <0.4), prior lower extremity amputation, loss of protective sensation, end-stage renal disease, and a history of walking barefoot.15,17,18

Appropriate classification of wound severity is critical in determining the need for hospitalization, antibiotic selection, surgical intervention, and prognosis. Multiple staging systems that incorporate physical examination findings, markers of systemic inflammation, and ischemia15,19,20 have been proposed. The Perfusion, Extent, Depth, Infection, and Sensation (PEDIS) grade was developed as a research tool and incorporates infection, ischemia, neuropathy, wound size, and systemic inflammation.15 The International Working Group on the Diabetic Foot (IWGDF) and the IDSA recommend use of the full or simplified PEDIS score in clinical practice (the IWGDF/IDSA Classification, Table 1) because these classifications predicted hospitalization and lower extremity amputation in prospective studies, with amputation rates of 3% for uninfected ulcers and up to 70% for severe infection.1,15 Patients with PEDIS grade 4 infections also have an increased mean length of stay compared with patients with grade 3 infections.21,22

CRITERIA FOR HOSPITALIZATION

In practice, the decision to admit is based on clinical and systems-based drivers (Supplementary Table 2). The IDSA and IWGDF guidelines recommend hospitalization for patients with severe (PEDIS grade 4) infection, moderate (PEDIS grade 3) infection with certain complications (eg, severe PAD or lack of home support), an inability to comply with required outpatient treatment, lack of improvement with outpatient therapy, or presence of metabolic or hemodynamic instability.1,15 Clinicians must also consider the need for surgical debridement or complex antibiotic choices due to allergies and comorbidities. Hospitalists may also consider admission in cases in which outpatient follow-up cannot be easily arranged (eg, uninsured patients).

Outpatient management may be appropriate for patients with mild infections who are willing to be reassessed within 72 hours, or sooner if the infection worsens.23 For patients with moderate infections (eg, osteomyelitis without systemic signs of infection), access to an outpatient interprofessional DFI care team can potentially decrease the need for admission.

DIAGNOSIS OF OSTEOMYELITIS

Clinical features that raise suspicion for osteomyelitis include ulceration for at least 6 weeks with appropriate wound care and offloading, wound extension to the bone or joint, exposed bone, ulcers larger than 2 cm2, previous history of a wound, multiple wounds, and appearance of a sausage digit.15

The gold standard for diagnosis of osteomyelitis is a bone biopsy with histology. In the absence of histology, physicians rely on physical examination, inflammatory markers, and imaging to make the diagnosis. The presence of visible, chronically exposed bone within a forefoot ulcer is diagnostic. The accuracy of a probe to bone test depends on the pretest probability of osteomyelitis. Sensitivity and specificity range from 60% to 87% and from 85% to 91%, respectively.24 For patients with a single forefoot ulcer and PEDIS grade 2 or 3 infection, considering both ulcer depth and serum inflammatory markers (ulcer depth greater than 3 mm, or C-reactive protein greater than 3.2 mg/dL; ulcer depth greater than 3 mm, or erythrocyte sedimentation rate greater than 60 mm/h) increases sensitivity to 100%, although the specificity is relatively low (55% and 60%, respectively).25 When the diagnosis remains uncertain by physical examination, imaging is necessary for further evaluation.

ROLE OF IMAGING

All patients with DFI should have plain radiographs to look for foot deformities, soft tissue gas, foreign bodies, and osteomyelitis. If plain radiographs show classic evidence of osteomyelitis, (ie, cortical erosion, periosteal reaction, mixed lucency, and sclerosis in the absence of neuro-osteoarthropathy), advanced imaging is not necessary. However, these changes may not appear on plain films for up to 1 month after infection onset.15,26

The purpose of advanced imaging in the inpatient management of DFI is to detect conditions not obvious by physical examination or by plain radiographs that would alter surgical management (ie, deep abscess or necrotic bone) or antibiotic duration (ie, osteomyelitis or tenosynovitis).15 Magnetic resonance imaging (MRI) is the diagnostic modality of choice when the wound does not probe to bone and the diagnosis remains uncertain27 due to its accuracy and availability.1,15 However, MRI cannot always distinguish between infection and neuro-osteoarthropathy, especially in patients who have infection superimposed on a Charcot foot, have had recent surgical intervention, or have osteosynthesis material at the infection site.24 If MRI is contraindicated, guidelines vary on the next recommended test. The IDSA and the Society for Vascular Surgery recommend a labeled white blood cell scan combined with a bone scan, whereas the IWGDF recommends a labeled leukocyte scan, a single photon emission computed tomography (SPECT/CT), or a fluorodeoxyglucose positron emission tomography (FDG PET) scan.1,15,19 A recent comparison of a labeled white blood cell SPECT/CT versus MRI (using histology as the gold standard) reported that SPECT/CT had a similar sensitivity (89% versus 87%, respectively) and specificity (35% versus 37%, respectively) to MRI.28 In practice, physicians should consider which studies are readily available and confidently interpreted by radiologists at their institution.

ASSESSMENT OF ULCER ETIOLOGY

After infection is diagnosed and staged, clinicians should determine the underlying derangement in order to prevent recurrence after discharge. Common derangements leading to ulceration in diabetics include PAD, neuropathy, muscular tension, altered foot mechanics, trauma, or a combination of the above.1,15,29-31 All patients with DFI should undergo pedal perfusion assessment by an ABI, ankle and pedal Doppler arterial waveforms, and either toe brachial index (TBI) or transcutaneous oxygen pressure.1,15,19 In cases of suspected calcification, TBI is a more reliable measure of ischemia compared with the ABI.16,19 For patients with signs and symptoms of ischemia and an abnormal ABI or TBI measurement (ABI <0.9 and TBI <0.7), a nonurgent consultation with a vascular surgeon is recommended, while patients with severe ischemia (ABI <0.4) usually require urgent revascularization.15,32

A sensory examination with a Semmes-Weinstein monofilament should be conducted to identify patients with loss of protective sensation who may benefit from offloading devices and custom orthotics.15 Foot anatomy and mechanics as well as potential Achilles tendon contractures should be evaluated by a foot specialist such as a podiatrist, orthotist, orthopedist, or vascular surgeon, especially if debridement or amputation is being contemplated.

OBTAINING CULTURES

After diagnosing the infection clinically, appropriately obtained cultures are essential to guide therapy in all except mild cases with no prior antibiotic exposure or MRSA risk.1,15 Guidelines strongly recommend that specimens be obtained by biopsy or curettage from deep tissue at the base of the ulcer after the wound has been cleansed and debrided and prior to initiating antibiotics.1,15,33 Aspiration of purulent secretions using a sterile needle and syringe is another acceptable culturing method.15 While convenient, swab cultures are prone to both false-positive and false-negative results.34 Repeat cultures are only needed for patients who are not responding to treatment or for surveillance of resistant organisms.1

In cases of osteomyelitis, bone specimens should be sent for culture and histology either during surgical debridement or a bone biopsy. At the time of debridement, cultures and pathology should be sent from the proximal (clean) bone margin in order to document whether there is residual osteomyelitis postdebridement.35 For patients not planned for debridement, a bone biopsy is recommended if the diagnosis of osteomyelitis is unclear, response to empiric therapy is poor, broad-spectrum antibiotics are being considered, or the infection is in the midfoot or hindfoot.1,15,19 Results from soft tissue or sinus tract specimens should not be used to guide antibiotic selection in osteomyelitis, as several studies suggest that they do not correlate with bone culture results; one retrospective review found a mere 22.5% correlation between wound swabs and bone biopsy.1,36 A 2-week antibiotic-free period prior to biopsy is recommended in order to minimize the risk of false-negative results but must be balanced with the risk of worsening infection.1,15 If possible, the biopsy should be performed through uninfected tissue under fluoroscopy or CT guidance, with 2 to 3 cores obtained for culture and histology.1,15

INTERPROFESSIONAL INPATIENT CARE

A growing number of health systems have created inpatient and/or outpatient interprofessional diabetic foot care teams, and several studies demonstrated an association between these teams and a reduction in major amputations.7-11,13 The goal of the inpatient team is to rapidly triage patients with moderate to severe infections, expedite surgical interventions and culture collection, establish an effective treatment plan, and ensure adherence postdischarge to optimize outcomes. The common core of most teams includes podiatry, endocrinology, wound care, and vascular surgery, but team composition may vary based on the availability of local specialists with interest and expertise in DFI.9,10,33

The division of consultation between podiatry and orthopedic surgery is highly dependent upon individual practice patterns and hospital structure. In general, forefoot ulcers may be managed by podiatry or orthopedic surgery, while severe Charcot deformities are most often treated by orthopedic surgeons. Wound care nurses are often integral to successful wound healing, collaborating across specialties and serving as a weekly or biweekly point of contact for patients.

Early involvement of Infectious Disease (ID) specialists can be useful for guiding antibiotic choices and facilitating follow-up. ID should be involved with patients who require long-term antibiotic therapy (ie, cases of deep-tissue infection that are not completely amputated or debrided), have failed outpatient or empiric therapy, have antibiotic allergies or drug-resistant pathogens, or are being considered for outpatient parenteral antibiotic therapy.

ANTIBIOTIC THERAPY

Empiric antibiotic therapy should be based on infection severity and the likely causative agent (Figure). Mild cases are managed with oral agents that target Staphylococcus aureus and Streptococcus species such as cephalexin or clindamycin.1,15 Antibiotics for moderate (PEDIS grade 3) infections can be oral or parenteral (eg, ampicillin-sulbactam or ertapenem) and should include coverage for the above pathogens in addition to Enterobacteriaciae and anaerobes.1,15 Empiric anti-MRSA coverage is optional in mild to moderate infections and should be reserved for patients with known risk factors, such as prior colonization, recent hospitalization, residence in a chronic care facility, previous amputation, or a high local prevalence of MRSA (50% MRSA prevalence for mild infections or 30% prevalence for moderate infections). 1,15Fluoroquinolones are no longer effective against S. aureus in most of the United States and should not be used as monotherapy if MRSA is suspected.37,38 A recent retrospective observational study found that ceftaroline fosamil treatment of DFI was associated with an 81% success rate, including for patients with comorbidities, MRSA, mixed infections, or surgical intervention, but it has not yet been studied in a comparative trial.39 Antipseudomonal therapy is not necessary in most moderate cases and should be reserved for patients who have severe infections (PEDIS grade 4) or specific risk-factors for Pseudomonas.1,15 Severe infections, gangrenous wounds, or necrotizing infections require parenteral agents to cover MRSA (ie, vancomycin or daptomycin), Pseudomonas (ie, cefepime or piperacillin-tazobactam), and anaerobes. 1,15 Anaerobic coverage must be added to cefepime but is not necessary with piperacillin-tazobactam or meropenem.40 Definitive therapy should be based on culture results, sensitivity testing, and the patient’s clinical response to the empiric regimen.15

The duration of antibiotic treatment for DFI is based on the severity of infection and response to treatment (Supplementary Table 3). Treatment should continue until the signs and symptoms of infection resolve, but there is no strong evidence to support treatment through complete healing. Healing will usually occur in 1 to 2 weeks for mild infections and in 2 to 3 weeks for moderate or severe infections. However, prescribing antibiotics for a fixed duration is not recommended and can result in an inadequate or unnecessarily prolonged course, with the potential for increased costs, adverse events, and antibiotic resistance.1,15,16 Therapy may be shortened by debridement, resection, or amputation, or lengthened in patients who are immunocompromised; have deep, large, necrotic, or poorly perfused wounds; do not undergo resection; or have an implanted foreign body at the infection site.1 If the patient does not improve despite targeted antibiotic treatment, providers should assess the need to revascularize, repeat debridement for new cultures, resect any progression of infection, or modify the antibiotic regimen to maximize tissue penetration and minimize drug interactions.1

Traditional management of diabetic foot osteomyelitis has relied almost exclusively on resection of all infected bone. However, data have emerged over the last 10 years to support initial medical management of select patients. Further research regarding the optimal treatment regimen and duration is ongoing, with 1 recent, randomized control trial comparing 6 versus 12 weeks of antibiotics for patients treated medically for osteomyelitis finding no difference in remission rates.1,41 Patients managed surgically for osteomyelitis are often treated parenterally for at least 4 weeks, but this practice is not based on strong evidence, and guidelines suggest most patients could be switched to highly bioavailable oral agents after a shorter course of intravenous therapy.1,15 Guidelines recommend 2 to 5 days of antibiotics after complete resection of infected bone and soft tissue (Supplementary Table 3). If the infected soft tissue remains, 1 to 3 weeks of therapy is usually sufficient, while 4 to 6 weeks is often needed if there is residually infected but viable bone.15

SURGICAL MANAGEMENT

Inpatient providers should be familiar with the indications for surgery in DFI patients in order to effectively utilize surgical consultants and ensure critical procedures are completed prior to discharge. Surgical consultation, preferably with a surgeon skilled in foot preservation, is recommended for patients with moderate or severe infections.1,15,33 Surgical indications include abscess, necrosis, compartment syndrome, refractory sepsis despite antibiotics, and extensive bone or joint destruction underlying the open wound, as well as other conditions listed in Table 2. While debridement often aids wound healing, it should be avoided in cases with dry eschar, especially when ischemia is present, as the infection will usually resolve with autoamputation.1,42,43

In patients with osteomyelitis, the decision between medical and surgical management is complex. Absolute indications for surgical resection include systemic toxicity with associated tissue infection, an open or infected joint space, and patients with prosthetic heart valves.27 However, the need for surgery is unclear beyond these absolute indications, and approximately two-thirds of osteomyelitis cases may be arrested or cured with antibiotic therapy alone.1 A prospective randomized comparative trial of patients with diabetic foot osteomyelitis found that patients treated with 90 days of antibiotics had similar healing rates, times to healing, and short-term complications as compared with those who underwent conservative bone resection.44 While further research is needed to determine which types of patients with osteomyelitis may be successfully treated without surgery, the IWGDF, the IDSA, and osteomyelitis experts have offered guidance on this decision (Table 2).1,15,27 If resection is necessary, hospitalists should request at least 4 specimens to help guide postoperative antibiotic therapy (1 sample for histology and 1 for microbiology, at both the grossly abnormal bone and the bone margin), as negative margin cultures predict a lower relapse risk for infection.1,35

Every effort should be made to preserve the limb, and urgent amputation is rarely needed except in cases with extensive necrosis or life-threatening infection. Elective amputation may be considered for patients who have recurrent ulceration or irreversible loss of foot function or who would require an excessively prolonged or intensive hospital stay.15 All patients with plantar ulcers that are unresponsive to conservative management and limited ankle dorsiflexion should be evaluated for pressure-relieving surgeries, such as Achilles lengthening and gastrocnemius recession.45,46 Studies suggest that pressure-relieving surgeries can increase rates of ulcer healing from 88% to 100% when added to total contact casting.47

CRITERIA FOR DISCHARGE

Guidelines suggest that patients be clinically stable before discharge, complete any urgent surgery, achieve acceptable glycemic control, and be presented with a comprehensive outpatient plan, including antibiotic therapy, offloading, wound care instructions, and outpatient follow-up (Supplementary Table 4). Physicians must consider patient and family preferences, expected adherence to therapy, availability of home support, and payer and cost issues when creating the discharge plan.15

INTERPROFESSIONAL OUTPATIENT CARE

An effective outpatient care team is critical to ensure wound healing and infection resolution. Efforts should be made to discharge patients to a comprehensive outpatient interprofessional foot care team, with a plan that includes professional foot care, patient education, and adequate footwear.48 Team composition varies but often includes representatives from vascular surgery, podiatry, orthotics, wound care, endocrinology, orthopedics, physical therapy and rehabilitation, infectious disease, and dermatology.11-13Interprofessional outpatient clinics can ease the burden of transportation and shorten the time to needed interventions in the case of treatment failure. Follow-up appointments within 1 to 2 weeks postdischarge have been found to reduce the risk of readmission in other high-risk conditions, and this is a reasonable time frame for DFI as well.49

CONCLUSION

DFIs are a common cause of morbidity in patients with diabetes and result in significant costs to the US healthcare system. Hospitalized patients with a DFI require appropriate classification of wound severity and assessment of vascular status, protective sensation, and potential osteomyelitis. Inpatient management of these patients includes obtaining necessary cultures, choosing an antibiotic regimen based on infection severity and the likely causative agent, and evaluating the need for surgical intervention. Prior to discharge, providers should determine a comprehensive follow-up plan and ensure patient engagement. Finally, interprofessional management has been shown to improve outcomes in DFI and should be adopted in both the inpatient and outpatient settings.

Disclosure

The authors report no conflicts of interest.

Diabetic foot infection (DFI) is a common result of diabetes and represents the most frequent complication requiring hospitalization and lower extremity amputation.1,2 Hospital discharges related to diabetic lower extremity ulcers increased from 72,000 in 1988 to 113,000 in 2007,3 and admissions related to infection rose 30% between 2005 and 2010.2 Ulceration and amputation are associated with a 40% to 50% 5-year mortality rate.4,5

Aggressive risk-factor management and interprofessional care can significantly reduce major amputations and mortality.6-13 Consistent and high-quality care for patients admitted with DFI is essential for optimizing outcomes; however, management varies widely, and critical assessment and prevention measures are often not employed by providers.14 This review synthesizes recommendations from existing guidelines to provide an overview of the best practices for the diagnosis, management, and discharge of DFI in the hospital setting (Supplementary Table 1, Supplementary Figure).

DETECTION AND STAGING OF INFECTION

The first step in the management of a DFI is a careful assessment of the presence and depth of infection.15 The Infectious Diseases Society of America (IDSA) guidelines recommend using at least 2 signs of classic inflammation (erythema, warmth, swelling, tenderness, or pain) or purulent drainage to diagnose soft tissue infection.1,15,16 Patients with ischemia may present atypically, with nonpurulent secretions, friable or discolored granulation tissue, undermining of wound edges, and foul odor. 1,15,16 Additional risk factors for DFI include ulceration for more than 30 days, recurrent foot ulcers, a traumatic foot wound, severe peripheral arterial disease (PAD) in the affected limb (ankle brachial index [ABI] <0.4), prior lower extremity amputation, loss of protective sensation, end-stage renal disease, and a history of walking barefoot.15,17,18

Appropriate classification of wound severity is critical in determining the need for hospitalization, antibiotic selection, surgical intervention, and prognosis. Multiple staging systems that incorporate physical examination findings, markers of systemic inflammation, and ischemia15,19,20 have been proposed. The Perfusion, Extent, Depth, Infection, and Sensation (PEDIS) grade was developed as a research tool and incorporates infection, ischemia, neuropathy, wound size, and systemic inflammation.15 The International Working Group on the Diabetic Foot (IWGDF) and the IDSA recommend use of the full or simplified PEDIS score in clinical practice (the IWGDF/IDSA Classification, Table 1) because these classifications predicted hospitalization and lower extremity amputation in prospective studies, with amputation rates of 3% for uninfected ulcers and up to 70% for severe infection.1,15 Patients with PEDIS grade 4 infections also have an increased mean length of stay compared with patients with grade 3 infections.21,22

CRITERIA FOR HOSPITALIZATION

In practice, the decision to admit is based on clinical and systems-based drivers (Supplementary Table 2). The IDSA and IWGDF guidelines recommend hospitalization for patients with severe (PEDIS grade 4) infection, moderate (PEDIS grade 3) infection with certain complications (eg, severe PAD or lack of home support), an inability to comply with required outpatient treatment, lack of improvement with outpatient therapy, or presence of metabolic or hemodynamic instability.1,15 Clinicians must also consider the need for surgical debridement or complex antibiotic choices due to allergies and comorbidities. Hospitalists may also consider admission in cases in which outpatient follow-up cannot be easily arranged (eg, uninsured patients).

Outpatient management may be appropriate for patients with mild infections who are willing to be reassessed within 72 hours, or sooner if the infection worsens.23 For patients with moderate infections (eg, osteomyelitis without systemic signs of infection), access to an outpatient interprofessional DFI care team can potentially decrease the need for admission.

DIAGNOSIS OF OSTEOMYELITIS

Clinical features that raise suspicion for osteomyelitis include ulceration for at least 6 weeks with appropriate wound care and offloading, wound extension to the bone or joint, exposed bone, ulcers larger than 2 cm2, previous history of a wound, multiple wounds, and appearance of a sausage digit.15

The gold standard for diagnosis of osteomyelitis is a bone biopsy with histology. In the absence of histology, physicians rely on physical examination, inflammatory markers, and imaging to make the diagnosis. The presence of visible, chronically exposed bone within a forefoot ulcer is diagnostic. The accuracy of a probe to bone test depends on the pretest probability of osteomyelitis. Sensitivity and specificity range from 60% to 87% and from 85% to 91%, respectively.24 For patients with a single forefoot ulcer and PEDIS grade 2 or 3 infection, considering both ulcer depth and serum inflammatory markers (ulcer depth greater than 3 mm, or C-reactive protein greater than 3.2 mg/dL; ulcer depth greater than 3 mm, or erythrocyte sedimentation rate greater than 60 mm/h) increases sensitivity to 100%, although the specificity is relatively low (55% and 60%, respectively).25 When the diagnosis remains uncertain by physical examination, imaging is necessary for further evaluation.

ROLE OF IMAGING

All patients with DFI should have plain radiographs to look for foot deformities, soft tissue gas, foreign bodies, and osteomyelitis. If plain radiographs show classic evidence of osteomyelitis, (ie, cortical erosion, periosteal reaction, mixed lucency, and sclerosis in the absence of neuro-osteoarthropathy), advanced imaging is not necessary. However, these changes may not appear on plain films for up to 1 month after infection onset.15,26

The purpose of advanced imaging in the inpatient management of DFI is to detect conditions not obvious by physical examination or by plain radiographs that would alter surgical management (ie, deep abscess or necrotic bone) or antibiotic duration (ie, osteomyelitis or tenosynovitis).15 Magnetic resonance imaging (MRI) is the diagnostic modality of choice when the wound does not probe to bone and the diagnosis remains uncertain27 due to its accuracy and availability.1,15 However, MRI cannot always distinguish between infection and neuro-osteoarthropathy, especially in patients who have infection superimposed on a Charcot foot, have had recent surgical intervention, or have osteosynthesis material at the infection site.24 If MRI is contraindicated, guidelines vary on the next recommended test. The IDSA and the Society for Vascular Surgery recommend a labeled white blood cell scan combined with a bone scan, whereas the IWGDF recommends a labeled leukocyte scan, a single photon emission computed tomography (SPECT/CT), or a fluorodeoxyglucose positron emission tomography (FDG PET) scan.1,15,19 A recent comparison of a labeled white blood cell SPECT/CT versus MRI (using histology as the gold standard) reported that SPECT/CT had a similar sensitivity (89% versus 87%, respectively) and specificity (35% versus 37%, respectively) to MRI.28 In practice, physicians should consider which studies are readily available and confidently interpreted by radiologists at their institution.

ASSESSMENT OF ULCER ETIOLOGY

After infection is diagnosed and staged, clinicians should determine the underlying derangement in order to prevent recurrence after discharge. Common derangements leading to ulceration in diabetics include PAD, neuropathy, muscular tension, altered foot mechanics, trauma, or a combination of the above.1,15,29-31 All patients with DFI should undergo pedal perfusion assessment by an ABI, ankle and pedal Doppler arterial waveforms, and either toe brachial index (TBI) or transcutaneous oxygen pressure.1,15,19 In cases of suspected calcification, TBI is a more reliable measure of ischemia compared with the ABI.16,19 For patients with signs and symptoms of ischemia and an abnormal ABI or TBI measurement (ABI <0.9 and TBI <0.7), a nonurgent consultation with a vascular surgeon is recommended, while patients with severe ischemia (ABI <0.4) usually require urgent revascularization.15,32

A sensory examination with a Semmes-Weinstein monofilament should be conducted to identify patients with loss of protective sensation who may benefit from offloading devices and custom orthotics.15 Foot anatomy and mechanics as well as potential Achilles tendon contractures should be evaluated by a foot specialist such as a podiatrist, orthotist, orthopedist, or vascular surgeon, especially if debridement or amputation is being contemplated.

OBTAINING CULTURES

After diagnosing the infection clinically, appropriately obtained cultures are essential to guide therapy in all except mild cases with no prior antibiotic exposure or MRSA risk.1,15 Guidelines strongly recommend that specimens be obtained by biopsy or curettage from deep tissue at the base of the ulcer after the wound has been cleansed and debrided and prior to initiating antibiotics.1,15,33 Aspiration of purulent secretions using a sterile needle and syringe is another acceptable culturing method.15 While convenient, swab cultures are prone to both false-positive and false-negative results.34 Repeat cultures are only needed for patients who are not responding to treatment or for surveillance of resistant organisms.1

In cases of osteomyelitis, bone specimens should be sent for culture and histology either during surgical debridement or a bone biopsy. At the time of debridement, cultures and pathology should be sent from the proximal (clean) bone margin in order to document whether there is residual osteomyelitis postdebridement.35 For patients not planned for debridement, a bone biopsy is recommended if the diagnosis of osteomyelitis is unclear, response to empiric therapy is poor, broad-spectrum antibiotics are being considered, or the infection is in the midfoot or hindfoot.1,15,19 Results from soft tissue or sinus tract specimens should not be used to guide antibiotic selection in osteomyelitis, as several studies suggest that they do not correlate with bone culture results; one retrospective review found a mere 22.5% correlation between wound swabs and bone biopsy.1,36 A 2-week antibiotic-free period prior to biopsy is recommended in order to minimize the risk of false-negative results but must be balanced with the risk of worsening infection.1,15 If possible, the biopsy should be performed through uninfected tissue under fluoroscopy or CT guidance, with 2 to 3 cores obtained for culture and histology.1,15

INTERPROFESSIONAL INPATIENT CARE

A growing number of health systems have created inpatient and/or outpatient interprofessional diabetic foot care teams, and several studies demonstrated an association between these teams and a reduction in major amputations.7-11,13 The goal of the inpatient team is to rapidly triage patients with moderate to severe infections, expedite surgical interventions and culture collection, establish an effective treatment plan, and ensure adherence postdischarge to optimize outcomes. The common core of most teams includes podiatry, endocrinology, wound care, and vascular surgery, but team composition may vary based on the availability of local specialists with interest and expertise in DFI.9,10,33

The division of consultation between podiatry and orthopedic surgery is highly dependent upon individual practice patterns and hospital structure. In general, forefoot ulcers may be managed by podiatry or orthopedic surgery, while severe Charcot deformities are most often treated by orthopedic surgeons. Wound care nurses are often integral to successful wound healing, collaborating across specialties and serving as a weekly or biweekly point of contact for patients.

Early involvement of Infectious Disease (ID) specialists can be useful for guiding antibiotic choices and facilitating follow-up. ID should be involved with patients who require long-term antibiotic therapy (ie, cases of deep-tissue infection that are not completely amputated or debrided), have failed outpatient or empiric therapy, have antibiotic allergies or drug-resistant pathogens, or are being considered for outpatient parenteral antibiotic therapy.

ANTIBIOTIC THERAPY

Empiric antibiotic therapy should be based on infection severity and the likely causative agent (Figure). Mild cases are managed with oral agents that target Staphylococcus aureus and Streptococcus species such as cephalexin or clindamycin.1,15 Antibiotics for moderate (PEDIS grade 3) infections can be oral or parenteral (eg, ampicillin-sulbactam or ertapenem) and should include coverage for the above pathogens in addition to Enterobacteriaciae and anaerobes.1,15 Empiric anti-MRSA coverage is optional in mild to moderate infections and should be reserved for patients with known risk factors, such as prior colonization, recent hospitalization, residence in a chronic care facility, previous amputation, or a high local prevalence of MRSA (50% MRSA prevalence for mild infections or 30% prevalence for moderate infections). 1,15Fluoroquinolones are no longer effective against S. aureus in most of the United States and should not be used as monotherapy if MRSA is suspected.37,38 A recent retrospective observational study found that ceftaroline fosamil treatment of DFI was associated with an 81% success rate, including for patients with comorbidities, MRSA, mixed infections, or surgical intervention, but it has not yet been studied in a comparative trial.39 Antipseudomonal therapy is not necessary in most moderate cases and should be reserved for patients who have severe infections (PEDIS grade 4) or specific risk-factors for Pseudomonas.1,15 Severe infections, gangrenous wounds, or necrotizing infections require parenteral agents to cover MRSA (ie, vancomycin or daptomycin), Pseudomonas (ie, cefepime or piperacillin-tazobactam), and anaerobes. 1,15 Anaerobic coverage must be added to cefepime but is not necessary with piperacillin-tazobactam or meropenem.40 Definitive therapy should be based on culture results, sensitivity testing, and the patient’s clinical response to the empiric regimen.15

The duration of antibiotic treatment for DFI is based on the severity of infection and response to treatment (Supplementary Table 3). Treatment should continue until the signs and symptoms of infection resolve, but there is no strong evidence to support treatment through complete healing. Healing will usually occur in 1 to 2 weeks for mild infections and in 2 to 3 weeks for moderate or severe infections. However, prescribing antibiotics for a fixed duration is not recommended and can result in an inadequate or unnecessarily prolonged course, with the potential for increased costs, adverse events, and antibiotic resistance.1,15,16 Therapy may be shortened by debridement, resection, or amputation, or lengthened in patients who are immunocompromised; have deep, large, necrotic, or poorly perfused wounds; do not undergo resection; or have an implanted foreign body at the infection site.1 If the patient does not improve despite targeted antibiotic treatment, providers should assess the need to revascularize, repeat debridement for new cultures, resect any progression of infection, or modify the antibiotic regimen to maximize tissue penetration and minimize drug interactions.1

Traditional management of diabetic foot osteomyelitis has relied almost exclusively on resection of all infected bone. However, data have emerged over the last 10 years to support initial medical management of select patients. Further research regarding the optimal treatment regimen and duration is ongoing, with 1 recent, randomized control trial comparing 6 versus 12 weeks of antibiotics for patients treated medically for osteomyelitis finding no difference in remission rates.1,41 Patients managed surgically for osteomyelitis are often treated parenterally for at least 4 weeks, but this practice is not based on strong evidence, and guidelines suggest most patients could be switched to highly bioavailable oral agents after a shorter course of intravenous therapy.1,15 Guidelines recommend 2 to 5 days of antibiotics after complete resection of infected bone and soft tissue (Supplementary Table 3). If the infected soft tissue remains, 1 to 3 weeks of therapy is usually sufficient, while 4 to 6 weeks is often needed if there is residually infected but viable bone.15

SURGICAL MANAGEMENT

Inpatient providers should be familiar with the indications for surgery in DFI patients in order to effectively utilize surgical consultants and ensure critical procedures are completed prior to discharge. Surgical consultation, preferably with a surgeon skilled in foot preservation, is recommended for patients with moderate or severe infections.1,15,33 Surgical indications include abscess, necrosis, compartment syndrome, refractory sepsis despite antibiotics, and extensive bone or joint destruction underlying the open wound, as well as other conditions listed in Table 2. While debridement often aids wound healing, it should be avoided in cases with dry eschar, especially when ischemia is present, as the infection will usually resolve with autoamputation.1,42,43

In patients with osteomyelitis, the decision between medical and surgical management is complex. Absolute indications for surgical resection include systemic toxicity with associated tissue infection, an open or infected joint space, and patients with prosthetic heart valves.27 However, the need for surgery is unclear beyond these absolute indications, and approximately two-thirds of osteomyelitis cases may be arrested or cured with antibiotic therapy alone.1 A prospective randomized comparative trial of patients with diabetic foot osteomyelitis found that patients treated with 90 days of antibiotics had similar healing rates, times to healing, and short-term complications as compared with those who underwent conservative bone resection.44 While further research is needed to determine which types of patients with osteomyelitis may be successfully treated without surgery, the IWGDF, the IDSA, and osteomyelitis experts have offered guidance on this decision (Table 2).1,15,27 If resection is necessary, hospitalists should request at least 4 specimens to help guide postoperative antibiotic therapy (1 sample for histology and 1 for microbiology, at both the grossly abnormal bone and the bone margin), as negative margin cultures predict a lower relapse risk for infection.1,35

Every effort should be made to preserve the limb, and urgent amputation is rarely needed except in cases with extensive necrosis or life-threatening infection. Elective amputation may be considered for patients who have recurrent ulceration or irreversible loss of foot function or who would require an excessively prolonged or intensive hospital stay.15 All patients with plantar ulcers that are unresponsive to conservative management and limited ankle dorsiflexion should be evaluated for pressure-relieving surgeries, such as Achilles lengthening and gastrocnemius recession.45,46 Studies suggest that pressure-relieving surgeries can increase rates of ulcer healing from 88% to 100% when added to total contact casting.47

CRITERIA FOR DISCHARGE

Guidelines suggest that patients be clinically stable before discharge, complete any urgent surgery, achieve acceptable glycemic control, and be presented with a comprehensive outpatient plan, including antibiotic therapy, offloading, wound care instructions, and outpatient follow-up (Supplementary Table 4). Physicians must consider patient and family preferences, expected adherence to therapy, availability of home support, and payer and cost issues when creating the discharge plan.15

INTERPROFESSIONAL OUTPATIENT CARE

An effective outpatient care team is critical to ensure wound healing and infection resolution. Efforts should be made to discharge patients to a comprehensive outpatient interprofessional foot care team, with a plan that includes professional foot care, patient education, and adequate footwear.48 Team composition varies but often includes representatives from vascular surgery, podiatry, orthotics, wound care, endocrinology, orthopedics, physical therapy and rehabilitation, infectious disease, and dermatology.11-13Interprofessional outpatient clinics can ease the burden of transportation and shorten the time to needed interventions in the case of treatment failure. Follow-up appointments within 1 to 2 weeks postdischarge have been found to reduce the risk of readmission in other high-risk conditions, and this is a reasonable time frame for DFI as well.49

CONCLUSION

DFIs are a common cause of morbidity in patients with diabetes and result in significant costs to the US healthcare system. Hospitalized patients with a DFI require appropriate classification of wound severity and assessment of vascular status, protective sensation, and potential osteomyelitis. Inpatient management of these patients includes obtaining necessary cultures, choosing an antibiotic regimen based on infection severity and the likely causative agent, and evaluating the need for surgical intervention. Prior to discharge, providers should determine a comprehensive follow-up plan and ensure patient engagement. Finally, interprofessional management has been shown to improve outcomes in DFI and should be adopted in both the inpatient and outpatient settings.

Disclosure

The authors report no conflicts of interest.

References

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5. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016;13(5):892-903. PubMed
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15. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173. PubMed
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26. Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis. 2004;39 Suppl 2:S115-S122. PubMed
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References

1. Lipsky BA, Aragón-Sánchez J, Diggle M, et al. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev. 2016;32 Suppl 1:45-74. PubMed
2. Hicks CW, Selvarajah S, Mathioudakis N, et al. Burden of infected diabetic foot ulcers on hospital admissions and costs. Ann Vasc Surg. 2016;33:149-158. PubMed
3. Number (in thousands) of hospital discharges with peripheral arterial disease (PAD), ulcer/inflammation/infection (ULCER), or neuropathy as first-listed diagnosis and diabetes as any-listed diagnosis United States, 1988-2007. Centers for Disease Control and Prevention website. http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig1_number.htm. Updated 2014. Accessed September 23, 2016.
4. Wilbek TE, Jansen RB, Jørgensen B, Svendsen OL. The diabetic foot in a multidisciplinary team setting. Number of amputations below ankle level and mortality. Exp Clin Endocrinol Diabetes. 2016;124(9):535-540. PubMed
5. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016;13(5):892-903. PubMed
6. Young MJ, McCardle JE, Randall LE, Barclay JI. Improved survival of diabetic foot ulcer patients 1995-2008: Possible impact of aggressive cardiovascular risk management. Diabetes Care. 2008;31(11):2143-2147PubMed
7. Troisi N, Baggiore C, Landini G, Michelagnoli S. How daily practice changed in an urban area after establishing a multidisciplinary diabetic foot program. J Diabetes. 2016;8(4):594-595. PubMed
8. Wang C, Mai L, Yang C, et al. Reducing major lower extremity amputations after the introduction of a multidisciplinary team in patient with diabetes foot ulcer. BMC Endocr Disord. 2016;16(1):38. PubMed
9. Rubio JA, Aragón-Sánchez J, Jiménez S, et al. Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot. Int J Low Extrem Wounds. 2014;13(1):22-26. PubMed
10. Yesil S, Akinci B, Bayraktar F, et al. Reduction of major amputations after starting a multidisciplinary diabetic foot care team: Single centre experience from Turkey. Exp Clin Endocrinol Diabetes. 2009;117(7):345-349. PubMed
11. Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: A prospective study. Diabetes Care. 1999;22(9):1428-1431. PubMed
12. Driver VR, Goodman RA, Fabbi M, French MA, Andersen CA. The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. J Am Podiatr Med Assoc. 2010;100(4):235-241. PubMed
13. Hamonet J, Verdié-Kessler C, Daviet JC, et al. Evaluation of a multidisciplinary consultation of diabetic foot. Ann Phys Rehabil Med. 2010;53(5):306-318. PubMed
14. Prompers L, Huijberts M, Apelqvist J, et al. Delivery of care to diabetic patients with foot ulcers in daily practice: Results of the Eurodiale study, a prospective cohort study. Diabet Med. 2008;25(6):700-707. PubMed
15. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173. PubMed
16. Noor S, Khan RU, Ahmad J. Understanding diabetic foot infection and its management. Diabetes Metab Syndr. 2016;11(2):149-156. PubMed
17. Hill MN, Feldman HI, Hilton SC, Holechek MJ, Ylitalo M, Benedict GW. Risk of foot complications in long-term diabetic patients with and without ESRD: A preliminary study. ANNA J. 1996;23(4):381-386; discussion 387-388. PubMed
18. Mohler ER, III. Peripheral arterial disease: Identification and implications. Arch Intern Med. 2003;163(19):2306-2314PubMed
19. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63(2 Suppl):3S-21S. PubMed
20. Noor S, Zubair M, Ahmad J. Diabetic foot ulcer--A review on pathophysiology, classification and microbial etiology. Diabetes Metab Syndr. 2015;9(3):192-199. PubMed
21. Wukich DK, Hobizal KB, Brooks MM. Severity of diabetic foot infection and rate of limb salvage. Foot Ankle Int. 2013;34(3):351-358. PubMed
22. Wukich DK, Hobizal KB, Raspovic KM, Rosario BL. SIRS is valid in discriminating between severe and moderate diabetic foot infections. Diabetes Care. 2013;36(11):3706-3711PubMed
23. Grigoropoulou P, Eleftheriadou I, Jude EB, Tentolouris N. Diabetic foot infections: An update in diagnosis and management. Curr Diab Rep. 2017;17(1):3. PubMed
24. Glaudemans AW, Uçkay I, Lipsky BA. Challenges in diagnosing infection in the diabetic foot. Diabet Med. 2015;32(6):748-759. PubMed
25. Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. J Foot Ankle Surg. 2009;48(1):39-46. PubMed
26. Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis. 2004;39 Suppl 2:S115-S122. PubMed
27. Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle. 2016;7:30079. PubMed
28. La Fontaine J, Bhavan K, Lam K, et al. Comparison between Tc-99m WBC SPECT/CT and MRI for the diagnosis of biopsy-proven diabetic foot osteomyelitis. Wounds. 2016;28(8):271-278. PubMed
29. Bembi V, Singh S, Singh P, Aneja GK, Arya TV, Arora R. Prevalence of peripheral arterial disease in a cohort of diabetic patients. South Med J. 2006;99(6):564-569. PubMed
30. Marso SP, Hiatt WR. Peripheral arterial disease in patients with diabetes. J Am Coll Cardiol. 2006;47(5):921-929. PubMed
31. Hinchliffe RJ, Andros G, Apelqvist J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012;28 Suppl 1:179-217. PubMed
32. Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ. Evidence-based management of PAD & the diabetic foot. Eur J Vasc Endovasc Surg. 2013;45(6):673-681. PubMed

 

 

33. 2015;13(2):115-122.Ann Fam Med49. Jackson C, Shahsahebi M, Wedlake T, DuBard CA. Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge. PubMed
34. 2016;32 Suppl 1:16-24.Diabetes Metab Res Rev48. Bus SA, van Netten JJ, Lavery LA, et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. PubMed
35. 2003;85-A(8):1436-1445.J Bone Joint Surg Am47. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. PubMed
36. 2015;21(2):77-85.Foot Ankle Surg46. Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. PubMed
37. 2016;32 Suppl 1:25-36.Diabetes Metab Res Rev45. Bus SA, Armstrong DG, van Deursen RW, et al. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. PubMed
38. 2014;37(3):789-795.Diabetes Care44. Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: A randomized comparative trial. PubMed
39. 1996;183(1):61-64.J Am Coll Surg43. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. PubMed
40. 2002;10(6):354-359.Wound Repair Regen42. Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. PubMed
41. 2015;38(2):302-307.Diabetes Care41. Tone A, Nguyen S, Devemy F, et al. Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: A multicenter open-label controlled randomized study. PubMed
42. 2014;35(10):1229-1235.Infect Control Hosp Epidemiol40. Schultz L, Lowe TJ, Srinivasan A, Neilson D, Pugliese G. Economic impact of redundant antimicrobial therapy in US hospitals. PubMed
43. 2015;31(4):395-401.Diabetes Metab Res Rev39. Lipsky BA, Cannon CM, Ramani A, et al. Ceftaroline fosamil for treatment of diabetic foot infections: the CAPTURE study experience. PubMed
2011;55(9):4154-4160.Antimicrob Agents Chemother.38. Richter SS, Heilmann KP, Dohrn CL, et al. Activity of ceftaroline and epidemiologic trends in Staphylococcus aureus isolates collected from 43 medical centers in the United States in 2009. PubMed
44. 2011;52(3):e18-e55.Clin Infect Dis37. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. PubMed
45. 2006;42(1):57-62.Clin Infect Dis36. Senneville E, Melliez H, Beltrand E, et al. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: Concordance with ulcer swab cultures. PubMed
46. 2012;51(6):749-752.J Foot Ankle Surg35. Atway S, Nerone VS, Springer KD, Woodruff DM. Rate of residual osteomyelitis after partial foot amputation in diabetic patients: A standardized method for evaluating bone margins with intraoperative culture. PubMed
47. 2010;5(7):415-420.J Hosp Med34. Chakraborti C, Le C, Yanofsky A. Sensitivity of superficial cultures in lower extremity wounds. PubMed
48. 2013;36(9):2862-2871.Diabetes Care33. Wukich DK, Armstrong DG, Attinger CE, et al. Inpatient management of diabetic foot disorders: A clinical guide. PubMed

 

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Consultation Improvement Teaching Module

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A case‐based teaching module combined with audit and feedback to improve the quality of consultations

An important role of the internist is that of inpatient medical consultant.13 As consultants, internists make recommendations regarding the patient's medical care and help the primary team to care for the patient. This requires familiarity with the body of knowledge of consultative medicine, as well as process skills that relate to working with teams of providers.1, 4, 5 For some physicians, the knowledge and skills of medical consultation are acquired during residency; however, many internists feel inadequately prepared for their roles of consultants.68 Because no specific requirements for medical consultation curricula during graduate medical education have been set forth, internists and other physicians do not receive uniform or comprehensive training in this area.3, 57, 9 Although internal medicine residents may gain experience while performing consultations on subspecialty rotations (eg, cardiology), the teaching on these blocks tends to be focused on the specialty content and less so on consultative principles.1, 4

As inpatient care is increasingly being taken over by hospitalists, the role of the hospitalist has expanded to include medical consultation. It is estimated that 92% of hospitalists care for patients on medical consultation services.8 The Society of Hospital Medicine (SHM) has also included medical consultation as one of the core competencies of the hospitalist.2 Therefore, it is essential that hospitalists master the knowledge and skills that are required to serve as effective consultants.10, 11

An educational strategy that has been shown to be effective in improving medical practice is audit and feedback.1215 Providing physicians with feedback on their clinical practice has been shown to improve performance more so than other educational methods.12 Practice‐based learning and improvement (PBLI) utilizes this strategy and it has become one of the core competencies stressed by the Accreditation Council for Graduate Medical Education (ACGME). It involves analyzing one's patient care practices in order to identify areas for improvement. In this study, we tested the impact of a newly developed one‐on‐one medical consultation educational module that was combined with audit and feedback in an attempt to improve the quality of the consultations being performed by our hospitalists.

Materials and Methods

Study Design and Setting

This single group pre‐post educational intervention study took place at Johns Hopkins Bayview Medical Center (JHBMC), a 353‐bed university‐affiliated tertiary care medical center in Baltimore, MD, during the 2006‐2007 academic year.

Study Subjects

All 7 members of the hospitalist group at JHBMC who were serving on the medical consultation service during the study period participated. The internal medicine residents who elected to rotate on the consultation service during the study period were also exposed to the case‐based module component of the intervention.

Intervention

The educational intervention was delivered as a one‐on‐one session and lasted approximately 1 hour. The time was spent on the following activities:

  • A true‐false pretest to assess knowledge based on clinical scenarios (Appendix 1).

  • A case‐based module emphasizing the core principles of consultative medicine.16 The module was purposively designed to teach and stimulate thought around 3 complex general medical consultations. These cases are followed by questions about scenarios. The cases specifically address the role of medical consultant and the ways to be most effective in this role based on the recommendations of experts in the field.1, 10 Additional details about the content and format can be viewed at http://www.jhcme.com/site.16 As the physician was working through the teaching cases, the teacher would facilitate discussion around wrong answers and issues that the learner wanted to discuss.

  • The true‐false test to assess knowledge was once again administered (the posttest was identical to the pretest).

  • For the hospitalist faculty members only (and not the residents), audit and feedback was utilized. The physician was shown 2 of his/her most recent consults and was asked to reflect upon the strengths and weaknesses of the consult. The hospitalist was explicitly asked to critique them in light of the knowledge they gained from the consultation module. The teacher also gave specific feedback, both positive and negative, about the written consultations with attention directed specifically toward: the number of recommendations, the specificity of the guidance (eg, exact dosing of medications), clear documentation of their name and contact information, and documentation that the suggestions were verbally passed on to the primary team.

 

Evaluation Data

Learner knowledge, both at baseline and after the case‐based module, was assessed using a written test.

Consultations performed before and after the intervention were compared. Copies of up to 5 consults done by each hospitalist during the year before or after the educational intervention were collected. Identifiers and dates were removed from the consults so that scorers did not know whether the consults were preintervention or postintervention. Consults were scored out of a possible total of 4 to 6 pointsdepending on whether specific elements were applicable. One point was given for each of the following: (1) number of recommendations 5; (2) specific details for all drugs listed [if applicable]; (3) specific details for imaging studies suggested [if applicable]; (4) specific follow‐up documented; (5) consultant's name being clearly written; and (6) verbal contact with the referring team documented. These 6 elements were included based on expert recommendation.10 All consults were scored by 2 hospitalists independently. Disagreements in scores were infrequent (on <10% of the 48 consults scored) and these were only off by 1 point for the overall score. The disagreements were settled by discussion and consensus. All consult scores were converted to a score out of 5, to allow comparisons to be made.

Following the intervention, each participant completed an overall assessment of the educational experience.

Data Analysis

We examined the frequency of responses for each variable and reviewed the distributions. The knowledge scores on the written pretests were not normally distributed and therefore when making comparisons to the posttest, we used the Wilcoxon rank signed test. In comparing the performance scores on the consults across the 2 time periods, we compared the results with both Wilcoxon rank signed test and paired t tests. Because the results were equivalent with both tests, the means from the t tests are shown. Data were analyzed using STATA version 8 (Stata Corp., College Station, TX).

Results

Study Subjects

Among the 14 hospitalist faculty members who were on staff during the study period, 7 were performing medical consults and therefore participated in the study. The 7 faculty members had a mean age of 35 years; 5 (71%) were female, and 5 (71%) were board‐certified in Internal Medicine. The average elapsed time since completion of residency was 5.1 years and average number of years practicing as a hospitalist was 3.8 years (Table 1).

Characteristics of the Faculty Members and House Officers Who Participated in the Study
Faculty (n = 7) 
Age in years, mean (SD)35.57 (5.1)
Female, n (%)5 (71%)
Board certified, n (%)5 (71%)
Years since completion of residency, mean (SD)5.1 (4.4)
Number of years in practice, mean (SD)3.8 (2.9)
Weeks spent in medical consult rotation, mean (SD)3.7 (0.8)
Have read consultation books, n (%)5 (71%)
Housestaff (n = 11) 
Age in years, mean (SD)29.1 (1.8)
Female, n (%)7 (64%)
Residency year, n (%) 
PGY10 (0%)
PGY22 (20%)
PGY37 (70%)
PGY41 (10%)
Weeks spent in medical consult rotation, mean (SD)1.5 (0.85)
Have read consultation books, n (%)5 (50%)

There were 12 house‐staff members who were on their medical consultation rotation during the study period and were exposed to the intervention. Of the 12 house‐staff members, 11 provided demographic information. Characteristics of the 11 house‐staff participants are also shown in Table 1.

Premodule vs. Postmodule Knowledge Assessment

Both faculty and house‐staff performed very well on the true/false pretest. The small changes in the median scores from pretest to posttest did not change significantly for the faculty (pretest: 11/14, posttest: 12/14; P = 0.08), but did reach statistical significance for the house‐staff (pretest: 10/14, posttest: 12/14; P = 0.03).

Audit and Feedback

Of the 7 faculty who participated in the study, 6 performed consults both before and after the intervention. Using the consult scoring system, the scores for all 6 physicians' consults improved after the intervention compared to their earlier consults (Table 2). For 1 faculty member, the consult scores were statistically significantly higher after the intervention (P = 0.017). When all consults completed by the hospitalists were compared before and after the training, there was statistically significant improvement in consult scores (P < 0.001) (Table 2).

Comparisons of Scores for the Consultations Performed Before and After the Intervention
 Preintervention (n =27)Postintervention (n = 21) 
ConsultantScores*MeanScores*MeanP value
  • Total possible score = 5.

  • P value obtained using t test. Significance of results was equivalent when analyzed using the Wilcoxon ranked sign test.

A2, 3, 3.75, 3, 2.52.83, 3, 3, 4, 43.40.093
B3, 3, 3, 3, 12.64, 3, 3, 2.53.10.18
C2, 1.671.84, 2, 33.00.11
D4, 2.5, 3.75, 2.5, 3.753.33.75, 33.40.45
E2, 3, 1, 2, 22.03, 3, 3.753.30.017
F3, 3.75, 2.5, 4, 23.12, 3.75, 4, 43.30.27
All 2.7 3.30.0006

Satisfaction with Consultation Curricula

All faculty and house‐staff participants felt that the intervention had an impact on them (19/19, 100%). Eighteen out of 19 participants (95%) would recommend the educational session to colleagues. After participating, 82% of learners felt confident in performing medical consultations. With respect to the audit and feedback process of reviewing their previously performed consultations, all physicians claimed that their written consultation notes would change in the future.

Discussion

This curricular intervention using a case‐based module combined with audit and feedback appears to have resulted not only in improved knowledge, but also changed physician behavior in the form of higher‐quality written consultations. The teaching sessions were also well received and valued by busy hospitalists.

A review of randomized trials of audit and feedback12 revealed that this strategy is effective in improving professional practice in a variety of areas, including laboratory overutilization,13, 14 clinical practice guideline adherence,15, 17 and antibiotic utilization.13 In 1 study, internal medicine specialists audited their consultation letters and most believed that there had been lasting improvements to their notes.18 However, this study did not objectively compare the consultation letters from before audit and feedback to those written afterward but instead relied solely on the respondents' self‐assessment. It is known that many residents and recent graduates of internal medicine programs feel inadequately prepared in the role of consultant.6, 8 This work describes a curricular intervention that served to augment confidence, knowledge, and actual performance in consultation medicine of physicians. Goldman et al.'s10 Ten Commandments for Effective Consultations, which were later modified by Salerno et al.,11 were highlighted in our case‐based teachings: determine the question being asked or how you can help the requesting physician, establish the urgency of the consultation, gather primary data, be as brief as appropriate in your report, provide specific recommendations, provide contingency plans and discuss their execution, define your role in conjunction with the requesting physician, offer educational information, communicate recommendations directly to the requesting physician, and provide daily follow‐up. These tenets informed the development of the consultation scoring system that was used to assess the quality of the written consultations produced by our consultant hospitalists.

Audit and feedback is similar to PBLI, one of the ACGME core competencies for residency training. Both attempt to engage individuals by having them analyze their patient care practices, looking critically to: (1) identify areas needing improvement, and (2) consider strategies that can be implemented to enhance clinical performance. We now show that consultative medicine is an area that appears to be responsive to a mixed methodological educational intervention that includes audit and feedback.

Faculty and house‐staff knowledge of consultative medicine was assessed both before and after the case‐based educational module. Both groups scored very highly on the true/false pretest, suggesting either that their knowledge was excellent at baseline or the test was not sufficiently challenging. If their knowledge was truly very high, then the intervention need not have focused on improving knowledge. It is our interpretation that the true/false knowledge assessment was not challenging enough and therefore failed to comprehensively characterize their knowledge of consultative medicine.

Several limitations of this study should be considered. First, the sample size was small, including only 7 faculty and 12 house‐staff members. However, these numbers were sufficient to show statistically significant overall improvements in both knowledge and on the consultation scores. Second, few consultations were performed by each faculty member, ranging from 2 to 5, before and after the intervention. This may explain why only 1 out of 6 faculty members showed statistically significant improvement in the quality of consults after the intervention. Third, the true/false format of the knowledge tests allowed the subjects to score very high on the pretest, thereby making it difficult to detect knowledge gained after the intervention. Fourth, the scale used to evaluate consults has not been previously validated. The elements assessed by this scale were decided upon based on guidance from the literature10 and the authors' expertise, thereby affording it content validity evidence.19 The recommendations that guided the scale's development have been shown to improve compliance with the recommendations put forth by the consultant.1, 11 Internal structure validity evidence was conferred by the high level of agreement in scores between the independent raters. Relation to other variables validity evidence may be considered because doctors D and F scored highest on this scale and they are the 2 physicians most experienced in consult medicine. Finally, the educational intervention was time‐intensive for both learners and teacher. It consisted of a 1 hour‐long one‐on‐one session. This can be difficult to incorporate into a busy hospitalist program. The intervention can be made more efficient by having learners take the web‐based module online independently, and then meeting with the teacher for the audit and feedback component.

This consult medicine curricular intervention involving audit and feedback was beneficial to hospitalists and resulted in improved consultation notes. While resource intensive, the one‐on‐one teaching session appears to have worked and resulted in outcomes that are meaningful with respect to patient care.

References
  1. Gross R, Caputo G.Kammerer and Gross' Medical Consultation: the Internist on Surgical, Obstetric, and Psychiatric Services.3rd ed.Baltimore:Williams and Wilkins;1998.
  2. Society of Hospital Medicine.Hospitalist as consultant.J Hosp Med.2006;1(S1):70.
  3. Deyo R.The internist as consultant.Arch Intern Med.1980;140:137138.
  4. Byyny R, Siegler M, Tarlov A.Development of an academic section of general internal medicine.Am J Med.1977;63(4):493498.
  5. Moore R, Kammerer W, McGlynn T, Trautlein J, Burnside J.Consultations in internal medicine: a training program resource.J Med Educ.1977;52(4):323327.
  6. Devor M, Renvall M, Ramsdell J.Practice patterns and the adequacy of residency training in consultation medicine.J Gen Intern Med.1993;8(10):554560.
  7. Bomalaski J, Martin G, Webster J.General internal medicine consultation: the last bridge.Arch Intern Med.1983;143:875876.
  8. Plauth W,Pantilat S, Wachter R, Fenton C.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111(3):247254.
  9. Robie P.The service and educational contributions of a general medicine consultation service.J Gen Intern Med.1986;1:225227.
  10. Goldman L, Lee T, Rudd P.Ten commandments for effective consultations.Arch Intern Med.1983;143:17531755.
  11. Salerno S, Hurst F, Halvorson S, Mercado D.Principles of effective consultation, an update for the 21st‐century consultant.Arch Intern Med.2007;167:271275.
  12. Jamtvedt G, Young J, Kristoffersen D, O'Brien M, Oxman A.Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback.Qual Saf Health Care.2006;15:433436.
  13. Miyakis S, Karamanof G, Liontos M, Mountokalakis T.Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy.Postgrad Med J.2006;82:823829.
  14. Winkens R, Pop P, Grol R, et al.Effects of routine individual feedback over nine years on general practitioners' requests for tests.BMJ.1996;312:490.
  15. Kisuule F, Wright S, Barreto J, Zenilman J.Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach.J Hosp Med.2008;3(1):6470.
  16. Feldman L, Minter‐Jordan M. The role of the medical consultant. Johns Hopkins Consultative Medicine Essentials for Hospitalists. Available at:http://www.jhcme.com/site/article.cfm?ID=8. Accessed April2009.
  17. Hysong S, Best R, Pugh J.Audit and feedback and clinical practice guideline adherence: making feedback actionable.Implement Sci.2006;1:9.
  18. Keely E, Myers K, Dojeiji S, Campbell C.Peer assessment of outpatient consultation letters—feasibility and satisfaction.BMC Med Educ.2007;7:13.
  19. Beckman TJ, Cook DA, Mandrekar JN.What is the validity evidence for assessment of clinical teaching?J Gen Intern Med.2005;20:11591164.
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An important role of the internist is that of inpatient medical consultant.13 As consultants, internists make recommendations regarding the patient's medical care and help the primary team to care for the patient. This requires familiarity with the body of knowledge of consultative medicine, as well as process skills that relate to working with teams of providers.1, 4, 5 For some physicians, the knowledge and skills of medical consultation are acquired during residency; however, many internists feel inadequately prepared for their roles of consultants.68 Because no specific requirements for medical consultation curricula during graduate medical education have been set forth, internists and other physicians do not receive uniform or comprehensive training in this area.3, 57, 9 Although internal medicine residents may gain experience while performing consultations on subspecialty rotations (eg, cardiology), the teaching on these blocks tends to be focused on the specialty content and less so on consultative principles.1, 4

As inpatient care is increasingly being taken over by hospitalists, the role of the hospitalist has expanded to include medical consultation. It is estimated that 92% of hospitalists care for patients on medical consultation services.8 The Society of Hospital Medicine (SHM) has also included medical consultation as one of the core competencies of the hospitalist.2 Therefore, it is essential that hospitalists master the knowledge and skills that are required to serve as effective consultants.10, 11

An educational strategy that has been shown to be effective in improving medical practice is audit and feedback.1215 Providing physicians with feedback on their clinical practice has been shown to improve performance more so than other educational methods.12 Practice‐based learning and improvement (PBLI) utilizes this strategy and it has become one of the core competencies stressed by the Accreditation Council for Graduate Medical Education (ACGME). It involves analyzing one's patient care practices in order to identify areas for improvement. In this study, we tested the impact of a newly developed one‐on‐one medical consultation educational module that was combined with audit and feedback in an attempt to improve the quality of the consultations being performed by our hospitalists.

Materials and Methods

Study Design and Setting

This single group pre‐post educational intervention study took place at Johns Hopkins Bayview Medical Center (JHBMC), a 353‐bed university‐affiliated tertiary care medical center in Baltimore, MD, during the 2006‐2007 academic year.

Study Subjects

All 7 members of the hospitalist group at JHBMC who were serving on the medical consultation service during the study period participated. The internal medicine residents who elected to rotate on the consultation service during the study period were also exposed to the case‐based module component of the intervention.

Intervention

The educational intervention was delivered as a one‐on‐one session and lasted approximately 1 hour. The time was spent on the following activities:

  • A true‐false pretest to assess knowledge based on clinical scenarios (Appendix 1).

  • A case‐based module emphasizing the core principles of consultative medicine.16 The module was purposively designed to teach and stimulate thought around 3 complex general medical consultations. These cases are followed by questions about scenarios. The cases specifically address the role of medical consultant and the ways to be most effective in this role based on the recommendations of experts in the field.1, 10 Additional details about the content and format can be viewed at http://www.jhcme.com/site.16 As the physician was working through the teaching cases, the teacher would facilitate discussion around wrong answers and issues that the learner wanted to discuss.

  • The true‐false test to assess knowledge was once again administered (the posttest was identical to the pretest).

  • For the hospitalist faculty members only (and not the residents), audit and feedback was utilized. The physician was shown 2 of his/her most recent consults and was asked to reflect upon the strengths and weaknesses of the consult. The hospitalist was explicitly asked to critique them in light of the knowledge they gained from the consultation module. The teacher also gave specific feedback, both positive and negative, about the written consultations with attention directed specifically toward: the number of recommendations, the specificity of the guidance (eg, exact dosing of medications), clear documentation of their name and contact information, and documentation that the suggestions were verbally passed on to the primary team.

 

Evaluation Data

Learner knowledge, both at baseline and after the case‐based module, was assessed using a written test.

Consultations performed before and after the intervention were compared. Copies of up to 5 consults done by each hospitalist during the year before or after the educational intervention were collected. Identifiers and dates were removed from the consults so that scorers did not know whether the consults were preintervention or postintervention. Consults were scored out of a possible total of 4 to 6 pointsdepending on whether specific elements were applicable. One point was given for each of the following: (1) number of recommendations 5; (2) specific details for all drugs listed [if applicable]; (3) specific details for imaging studies suggested [if applicable]; (4) specific follow‐up documented; (5) consultant's name being clearly written; and (6) verbal contact with the referring team documented. These 6 elements were included based on expert recommendation.10 All consults were scored by 2 hospitalists independently. Disagreements in scores were infrequent (on <10% of the 48 consults scored) and these were only off by 1 point for the overall score. The disagreements were settled by discussion and consensus. All consult scores were converted to a score out of 5, to allow comparisons to be made.

Following the intervention, each participant completed an overall assessment of the educational experience.

Data Analysis

We examined the frequency of responses for each variable and reviewed the distributions. The knowledge scores on the written pretests were not normally distributed and therefore when making comparisons to the posttest, we used the Wilcoxon rank signed test. In comparing the performance scores on the consults across the 2 time periods, we compared the results with both Wilcoxon rank signed test and paired t tests. Because the results were equivalent with both tests, the means from the t tests are shown. Data were analyzed using STATA version 8 (Stata Corp., College Station, TX).

Results

Study Subjects

Among the 14 hospitalist faculty members who were on staff during the study period, 7 were performing medical consults and therefore participated in the study. The 7 faculty members had a mean age of 35 years; 5 (71%) were female, and 5 (71%) were board‐certified in Internal Medicine. The average elapsed time since completion of residency was 5.1 years and average number of years practicing as a hospitalist was 3.8 years (Table 1).

Characteristics of the Faculty Members and House Officers Who Participated in the Study
Faculty (n = 7) 
Age in years, mean (SD)35.57 (5.1)
Female, n (%)5 (71%)
Board certified, n (%)5 (71%)
Years since completion of residency, mean (SD)5.1 (4.4)
Number of years in practice, mean (SD)3.8 (2.9)
Weeks spent in medical consult rotation, mean (SD)3.7 (0.8)
Have read consultation books, n (%)5 (71%)
Housestaff (n = 11) 
Age in years, mean (SD)29.1 (1.8)
Female, n (%)7 (64%)
Residency year, n (%) 
PGY10 (0%)
PGY22 (20%)
PGY37 (70%)
PGY41 (10%)
Weeks spent in medical consult rotation, mean (SD)1.5 (0.85)
Have read consultation books, n (%)5 (50%)

There were 12 house‐staff members who were on their medical consultation rotation during the study period and were exposed to the intervention. Of the 12 house‐staff members, 11 provided demographic information. Characteristics of the 11 house‐staff participants are also shown in Table 1.

Premodule vs. Postmodule Knowledge Assessment

Both faculty and house‐staff performed very well on the true/false pretest. The small changes in the median scores from pretest to posttest did not change significantly for the faculty (pretest: 11/14, posttest: 12/14; P = 0.08), but did reach statistical significance for the house‐staff (pretest: 10/14, posttest: 12/14; P = 0.03).

Audit and Feedback

Of the 7 faculty who participated in the study, 6 performed consults both before and after the intervention. Using the consult scoring system, the scores for all 6 physicians' consults improved after the intervention compared to their earlier consults (Table 2). For 1 faculty member, the consult scores were statistically significantly higher after the intervention (P = 0.017). When all consults completed by the hospitalists were compared before and after the training, there was statistically significant improvement in consult scores (P < 0.001) (Table 2).

Comparisons of Scores for the Consultations Performed Before and After the Intervention
 Preintervention (n =27)Postintervention (n = 21) 
ConsultantScores*MeanScores*MeanP value
  • Total possible score = 5.

  • P value obtained using t test. Significance of results was equivalent when analyzed using the Wilcoxon ranked sign test.

A2, 3, 3.75, 3, 2.52.83, 3, 3, 4, 43.40.093
B3, 3, 3, 3, 12.64, 3, 3, 2.53.10.18
C2, 1.671.84, 2, 33.00.11
D4, 2.5, 3.75, 2.5, 3.753.33.75, 33.40.45
E2, 3, 1, 2, 22.03, 3, 3.753.30.017
F3, 3.75, 2.5, 4, 23.12, 3.75, 4, 43.30.27
All 2.7 3.30.0006

Satisfaction with Consultation Curricula

All faculty and house‐staff participants felt that the intervention had an impact on them (19/19, 100%). Eighteen out of 19 participants (95%) would recommend the educational session to colleagues. After participating, 82% of learners felt confident in performing medical consultations. With respect to the audit and feedback process of reviewing their previously performed consultations, all physicians claimed that their written consultation notes would change in the future.

Discussion

This curricular intervention using a case‐based module combined with audit and feedback appears to have resulted not only in improved knowledge, but also changed physician behavior in the form of higher‐quality written consultations. The teaching sessions were also well received and valued by busy hospitalists.

A review of randomized trials of audit and feedback12 revealed that this strategy is effective in improving professional practice in a variety of areas, including laboratory overutilization,13, 14 clinical practice guideline adherence,15, 17 and antibiotic utilization.13 In 1 study, internal medicine specialists audited their consultation letters and most believed that there had been lasting improvements to their notes.18 However, this study did not objectively compare the consultation letters from before audit and feedback to those written afterward but instead relied solely on the respondents' self‐assessment. It is known that many residents and recent graduates of internal medicine programs feel inadequately prepared in the role of consultant.6, 8 This work describes a curricular intervention that served to augment confidence, knowledge, and actual performance in consultation medicine of physicians. Goldman et al.'s10 Ten Commandments for Effective Consultations, which were later modified by Salerno et al.,11 were highlighted in our case‐based teachings: determine the question being asked or how you can help the requesting physician, establish the urgency of the consultation, gather primary data, be as brief as appropriate in your report, provide specific recommendations, provide contingency plans and discuss their execution, define your role in conjunction with the requesting physician, offer educational information, communicate recommendations directly to the requesting physician, and provide daily follow‐up. These tenets informed the development of the consultation scoring system that was used to assess the quality of the written consultations produced by our consultant hospitalists.

Audit and feedback is similar to PBLI, one of the ACGME core competencies for residency training. Both attempt to engage individuals by having them analyze their patient care practices, looking critically to: (1) identify areas needing improvement, and (2) consider strategies that can be implemented to enhance clinical performance. We now show that consultative medicine is an area that appears to be responsive to a mixed methodological educational intervention that includes audit and feedback.

Faculty and house‐staff knowledge of consultative medicine was assessed both before and after the case‐based educational module. Both groups scored very highly on the true/false pretest, suggesting either that their knowledge was excellent at baseline or the test was not sufficiently challenging. If their knowledge was truly very high, then the intervention need not have focused on improving knowledge. It is our interpretation that the true/false knowledge assessment was not challenging enough and therefore failed to comprehensively characterize their knowledge of consultative medicine.

Several limitations of this study should be considered. First, the sample size was small, including only 7 faculty and 12 house‐staff members. However, these numbers were sufficient to show statistically significant overall improvements in both knowledge and on the consultation scores. Second, few consultations were performed by each faculty member, ranging from 2 to 5, before and after the intervention. This may explain why only 1 out of 6 faculty members showed statistically significant improvement in the quality of consults after the intervention. Third, the true/false format of the knowledge tests allowed the subjects to score very high on the pretest, thereby making it difficult to detect knowledge gained after the intervention. Fourth, the scale used to evaluate consults has not been previously validated. The elements assessed by this scale were decided upon based on guidance from the literature10 and the authors' expertise, thereby affording it content validity evidence.19 The recommendations that guided the scale's development have been shown to improve compliance with the recommendations put forth by the consultant.1, 11 Internal structure validity evidence was conferred by the high level of agreement in scores between the independent raters. Relation to other variables validity evidence may be considered because doctors D and F scored highest on this scale and they are the 2 physicians most experienced in consult medicine. Finally, the educational intervention was time‐intensive for both learners and teacher. It consisted of a 1 hour‐long one‐on‐one session. This can be difficult to incorporate into a busy hospitalist program. The intervention can be made more efficient by having learners take the web‐based module online independently, and then meeting with the teacher for the audit and feedback component.

This consult medicine curricular intervention involving audit and feedback was beneficial to hospitalists and resulted in improved consultation notes. While resource intensive, the one‐on‐one teaching session appears to have worked and resulted in outcomes that are meaningful with respect to patient care.

An important role of the internist is that of inpatient medical consultant.13 As consultants, internists make recommendations regarding the patient's medical care and help the primary team to care for the patient. This requires familiarity with the body of knowledge of consultative medicine, as well as process skills that relate to working with teams of providers.1, 4, 5 For some physicians, the knowledge and skills of medical consultation are acquired during residency; however, many internists feel inadequately prepared for their roles of consultants.68 Because no specific requirements for medical consultation curricula during graduate medical education have been set forth, internists and other physicians do not receive uniform or comprehensive training in this area.3, 57, 9 Although internal medicine residents may gain experience while performing consultations on subspecialty rotations (eg, cardiology), the teaching on these blocks tends to be focused on the specialty content and less so on consultative principles.1, 4

As inpatient care is increasingly being taken over by hospitalists, the role of the hospitalist has expanded to include medical consultation. It is estimated that 92% of hospitalists care for patients on medical consultation services.8 The Society of Hospital Medicine (SHM) has also included medical consultation as one of the core competencies of the hospitalist.2 Therefore, it is essential that hospitalists master the knowledge and skills that are required to serve as effective consultants.10, 11

An educational strategy that has been shown to be effective in improving medical practice is audit and feedback.1215 Providing physicians with feedback on their clinical practice has been shown to improve performance more so than other educational methods.12 Practice‐based learning and improvement (PBLI) utilizes this strategy and it has become one of the core competencies stressed by the Accreditation Council for Graduate Medical Education (ACGME). It involves analyzing one's patient care practices in order to identify areas for improvement. In this study, we tested the impact of a newly developed one‐on‐one medical consultation educational module that was combined with audit and feedback in an attempt to improve the quality of the consultations being performed by our hospitalists.

Materials and Methods

Study Design and Setting

This single group pre‐post educational intervention study took place at Johns Hopkins Bayview Medical Center (JHBMC), a 353‐bed university‐affiliated tertiary care medical center in Baltimore, MD, during the 2006‐2007 academic year.

Study Subjects

All 7 members of the hospitalist group at JHBMC who were serving on the medical consultation service during the study period participated. The internal medicine residents who elected to rotate on the consultation service during the study period were also exposed to the case‐based module component of the intervention.

Intervention

The educational intervention was delivered as a one‐on‐one session and lasted approximately 1 hour. The time was spent on the following activities:

  • A true‐false pretest to assess knowledge based on clinical scenarios (Appendix 1).

  • A case‐based module emphasizing the core principles of consultative medicine.16 The module was purposively designed to teach and stimulate thought around 3 complex general medical consultations. These cases are followed by questions about scenarios. The cases specifically address the role of medical consultant and the ways to be most effective in this role based on the recommendations of experts in the field.1, 10 Additional details about the content and format can be viewed at http://www.jhcme.com/site.16 As the physician was working through the teaching cases, the teacher would facilitate discussion around wrong answers and issues that the learner wanted to discuss.

  • The true‐false test to assess knowledge was once again administered (the posttest was identical to the pretest).

  • For the hospitalist faculty members only (and not the residents), audit and feedback was utilized. The physician was shown 2 of his/her most recent consults and was asked to reflect upon the strengths and weaknesses of the consult. The hospitalist was explicitly asked to critique them in light of the knowledge they gained from the consultation module. The teacher also gave specific feedback, both positive and negative, about the written consultations with attention directed specifically toward: the number of recommendations, the specificity of the guidance (eg, exact dosing of medications), clear documentation of their name and contact information, and documentation that the suggestions were verbally passed on to the primary team.

 

Evaluation Data

Learner knowledge, both at baseline and after the case‐based module, was assessed using a written test.

Consultations performed before and after the intervention were compared. Copies of up to 5 consults done by each hospitalist during the year before or after the educational intervention were collected. Identifiers and dates were removed from the consults so that scorers did not know whether the consults were preintervention or postintervention. Consults were scored out of a possible total of 4 to 6 pointsdepending on whether specific elements were applicable. One point was given for each of the following: (1) number of recommendations 5; (2) specific details for all drugs listed [if applicable]; (3) specific details for imaging studies suggested [if applicable]; (4) specific follow‐up documented; (5) consultant's name being clearly written; and (6) verbal contact with the referring team documented. These 6 elements were included based on expert recommendation.10 All consults were scored by 2 hospitalists independently. Disagreements in scores were infrequent (on <10% of the 48 consults scored) and these were only off by 1 point for the overall score. The disagreements were settled by discussion and consensus. All consult scores were converted to a score out of 5, to allow comparisons to be made.

Following the intervention, each participant completed an overall assessment of the educational experience.

Data Analysis

We examined the frequency of responses for each variable and reviewed the distributions. The knowledge scores on the written pretests were not normally distributed and therefore when making comparisons to the posttest, we used the Wilcoxon rank signed test. In comparing the performance scores on the consults across the 2 time periods, we compared the results with both Wilcoxon rank signed test and paired t tests. Because the results were equivalent with both tests, the means from the t tests are shown. Data were analyzed using STATA version 8 (Stata Corp., College Station, TX).

Results

Study Subjects

Among the 14 hospitalist faculty members who were on staff during the study period, 7 were performing medical consults and therefore participated in the study. The 7 faculty members had a mean age of 35 years; 5 (71%) were female, and 5 (71%) were board‐certified in Internal Medicine. The average elapsed time since completion of residency was 5.1 years and average number of years practicing as a hospitalist was 3.8 years (Table 1).

Characteristics of the Faculty Members and House Officers Who Participated in the Study
Faculty (n = 7) 
Age in years, mean (SD)35.57 (5.1)
Female, n (%)5 (71%)
Board certified, n (%)5 (71%)
Years since completion of residency, mean (SD)5.1 (4.4)
Number of years in practice, mean (SD)3.8 (2.9)
Weeks spent in medical consult rotation, mean (SD)3.7 (0.8)
Have read consultation books, n (%)5 (71%)
Housestaff (n = 11) 
Age in years, mean (SD)29.1 (1.8)
Female, n (%)7 (64%)
Residency year, n (%) 
PGY10 (0%)
PGY22 (20%)
PGY37 (70%)
PGY41 (10%)
Weeks spent in medical consult rotation, mean (SD)1.5 (0.85)
Have read consultation books, n (%)5 (50%)

There were 12 house‐staff members who were on their medical consultation rotation during the study period and were exposed to the intervention. Of the 12 house‐staff members, 11 provided demographic information. Characteristics of the 11 house‐staff participants are also shown in Table 1.

Premodule vs. Postmodule Knowledge Assessment

Both faculty and house‐staff performed very well on the true/false pretest. The small changes in the median scores from pretest to posttest did not change significantly for the faculty (pretest: 11/14, posttest: 12/14; P = 0.08), but did reach statistical significance for the house‐staff (pretest: 10/14, posttest: 12/14; P = 0.03).

Audit and Feedback

Of the 7 faculty who participated in the study, 6 performed consults both before and after the intervention. Using the consult scoring system, the scores for all 6 physicians' consults improved after the intervention compared to their earlier consults (Table 2). For 1 faculty member, the consult scores were statistically significantly higher after the intervention (P = 0.017). When all consults completed by the hospitalists were compared before and after the training, there was statistically significant improvement in consult scores (P < 0.001) (Table 2).

Comparisons of Scores for the Consultations Performed Before and After the Intervention
 Preintervention (n =27)Postintervention (n = 21) 
ConsultantScores*MeanScores*MeanP value
  • Total possible score = 5.

  • P value obtained using t test. Significance of results was equivalent when analyzed using the Wilcoxon ranked sign test.

A2, 3, 3.75, 3, 2.52.83, 3, 3, 4, 43.40.093
B3, 3, 3, 3, 12.64, 3, 3, 2.53.10.18
C2, 1.671.84, 2, 33.00.11
D4, 2.5, 3.75, 2.5, 3.753.33.75, 33.40.45
E2, 3, 1, 2, 22.03, 3, 3.753.30.017
F3, 3.75, 2.5, 4, 23.12, 3.75, 4, 43.30.27
All 2.7 3.30.0006

Satisfaction with Consultation Curricula

All faculty and house‐staff participants felt that the intervention had an impact on them (19/19, 100%). Eighteen out of 19 participants (95%) would recommend the educational session to colleagues. After participating, 82% of learners felt confident in performing medical consultations. With respect to the audit and feedback process of reviewing their previously performed consultations, all physicians claimed that their written consultation notes would change in the future.

Discussion

This curricular intervention using a case‐based module combined with audit and feedback appears to have resulted not only in improved knowledge, but also changed physician behavior in the form of higher‐quality written consultations. The teaching sessions were also well received and valued by busy hospitalists.

A review of randomized trials of audit and feedback12 revealed that this strategy is effective in improving professional practice in a variety of areas, including laboratory overutilization,13, 14 clinical practice guideline adherence,15, 17 and antibiotic utilization.13 In 1 study, internal medicine specialists audited their consultation letters and most believed that there had been lasting improvements to their notes.18 However, this study did not objectively compare the consultation letters from before audit and feedback to those written afterward but instead relied solely on the respondents' self‐assessment. It is known that many residents and recent graduates of internal medicine programs feel inadequately prepared in the role of consultant.6, 8 This work describes a curricular intervention that served to augment confidence, knowledge, and actual performance in consultation medicine of physicians. Goldman et al.'s10 Ten Commandments for Effective Consultations, which were later modified by Salerno et al.,11 were highlighted in our case‐based teachings: determine the question being asked or how you can help the requesting physician, establish the urgency of the consultation, gather primary data, be as brief as appropriate in your report, provide specific recommendations, provide contingency plans and discuss their execution, define your role in conjunction with the requesting physician, offer educational information, communicate recommendations directly to the requesting physician, and provide daily follow‐up. These tenets informed the development of the consultation scoring system that was used to assess the quality of the written consultations produced by our consultant hospitalists.

Audit and feedback is similar to PBLI, one of the ACGME core competencies for residency training. Both attempt to engage individuals by having them analyze their patient care practices, looking critically to: (1) identify areas needing improvement, and (2) consider strategies that can be implemented to enhance clinical performance. We now show that consultative medicine is an area that appears to be responsive to a mixed methodological educational intervention that includes audit and feedback.

Faculty and house‐staff knowledge of consultative medicine was assessed both before and after the case‐based educational module. Both groups scored very highly on the true/false pretest, suggesting either that their knowledge was excellent at baseline or the test was not sufficiently challenging. If their knowledge was truly very high, then the intervention need not have focused on improving knowledge. It is our interpretation that the true/false knowledge assessment was not challenging enough and therefore failed to comprehensively characterize their knowledge of consultative medicine.

Several limitations of this study should be considered. First, the sample size was small, including only 7 faculty and 12 house‐staff members. However, these numbers were sufficient to show statistically significant overall improvements in both knowledge and on the consultation scores. Second, few consultations were performed by each faculty member, ranging from 2 to 5, before and after the intervention. This may explain why only 1 out of 6 faculty members showed statistically significant improvement in the quality of consults after the intervention. Third, the true/false format of the knowledge tests allowed the subjects to score very high on the pretest, thereby making it difficult to detect knowledge gained after the intervention. Fourth, the scale used to evaluate consults has not been previously validated. The elements assessed by this scale were decided upon based on guidance from the literature10 and the authors' expertise, thereby affording it content validity evidence.19 The recommendations that guided the scale's development have been shown to improve compliance with the recommendations put forth by the consultant.1, 11 Internal structure validity evidence was conferred by the high level of agreement in scores between the independent raters. Relation to other variables validity evidence may be considered because doctors D and F scored highest on this scale and they are the 2 physicians most experienced in consult medicine. Finally, the educational intervention was time‐intensive for both learners and teacher. It consisted of a 1 hour‐long one‐on‐one session. This can be difficult to incorporate into a busy hospitalist program. The intervention can be made more efficient by having learners take the web‐based module online independently, and then meeting with the teacher for the audit and feedback component.

This consult medicine curricular intervention involving audit and feedback was beneficial to hospitalists and resulted in improved consultation notes. While resource intensive, the one‐on‐one teaching session appears to have worked and resulted in outcomes that are meaningful with respect to patient care.

References
  1. Gross R, Caputo G.Kammerer and Gross' Medical Consultation: the Internist on Surgical, Obstetric, and Psychiatric Services.3rd ed.Baltimore:Williams and Wilkins;1998.
  2. Society of Hospital Medicine.Hospitalist as consultant.J Hosp Med.2006;1(S1):70.
  3. Deyo R.The internist as consultant.Arch Intern Med.1980;140:137138.
  4. Byyny R, Siegler M, Tarlov A.Development of an academic section of general internal medicine.Am J Med.1977;63(4):493498.
  5. Moore R, Kammerer W, McGlynn T, Trautlein J, Burnside J.Consultations in internal medicine: a training program resource.J Med Educ.1977;52(4):323327.
  6. Devor M, Renvall M, Ramsdell J.Practice patterns and the adequacy of residency training in consultation medicine.J Gen Intern Med.1993;8(10):554560.
  7. Bomalaski J, Martin G, Webster J.General internal medicine consultation: the last bridge.Arch Intern Med.1983;143:875876.
  8. Plauth W,Pantilat S, Wachter R, Fenton C.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111(3):247254.
  9. Robie P.The service and educational contributions of a general medicine consultation service.J Gen Intern Med.1986;1:225227.
  10. Goldman L, Lee T, Rudd P.Ten commandments for effective consultations.Arch Intern Med.1983;143:17531755.
  11. Salerno S, Hurst F, Halvorson S, Mercado D.Principles of effective consultation, an update for the 21st‐century consultant.Arch Intern Med.2007;167:271275.
  12. Jamtvedt G, Young J, Kristoffersen D, O'Brien M, Oxman A.Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback.Qual Saf Health Care.2006;15:433436.
  13. Miyakis S, Karamanof G, Liontos M, Mountokalakis T.Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy.Postgrad Med J.2006;82:823829.
  14. Winkens R, Pop P, Grol R, et al.Effects of routine individual feedback over nine years on general practitioners' requests for tests.BMJ.1996;312:490.
  15. Kisuule F, Wright S, Barreto J, Zenilman J.Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach.J Hosp Med.2008;3(1):6470.
  16. Feldman L, Minter‐Jordan M. The role of the medical consultant. Johns Hopkins Consultative Medicine Essentials for Hospitalists. Available at:http://www.jhcme.com/site/article.cfm?ID=8. Accessed April2009.
  17. Hysong S, Best R, Pugh J.Audit and feedback and clinical practice guideline adherence: making feedback actionable.Implement Sci.2006;1:9.
  18. Keely E, Myers K, Dojeiji S, Campbell C.Peer assessment of outpatient consultation letters—feasibility and satisfaction.BMC Med Educ.2007;7:13.
  19. Beckman TJ, Cook DA, Mandrekar JN.What is the validity evidence for assessment of clinical teaching?J Gen Intern Med.2005;20:11591164.
References
  1. Gross R, Caputo G.Kammerer and Gross' Medical Consultation: the Internist on Surgical, Obstetric, and Psychiatric Services.3rd ed.Baltimore:Williams and Wilkins;1998.
  2. Society of Hospital Medicine.Hospitalist as consultant.J Hosp Med.2006;1(S1):70.
  3. Deyo R.The internist as consultant.Arch Intern Med.1980;140:137138.
  4. Byyny R, Siegler M, Tarlov A.Development of an academic section of general internal medicine.Am J Med.1977;63(4):493498.
  5. Moore R, Kammerer W, McGlynn T, Trautlein J, Burnside J.Consultations in internal medicine: a training program resource.J Med Educ.1977;52(4):323327.
  6. Devor M, Renvall M, Ramsdell J.Practice patterns and the adequacy of residency training in consultation medicine.J Gen Intern Med.1993;8(10):554560.
  7. Bomalaski J, Martin G, Webster J.General internal medicine consultation: the last bridge.Arch Intern Med.1983;143:875876.
  8. Plauth W,Pantilat S, Wachter R, Fenton C.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111(3):247254.
  9. Robie P.The service and educational contributions of a general medicine consultation service.J Gen Intern Med.1986;1:225227.
  10. Goldman L, Lee T, Rudd P.Ten commandments for effective consultations.Arch Intern Med.1983;143:17531755.
  11. Salerno S, Hurst F, Halvorson S, Mercado D.Principles of effective consultation, an update for the 21st‐century consultant.Arch Intern Med.2007;167:271275.
  12. Jamtvedt G, Young J, Kristoffersen D, O'Brien M, Oxman A.Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback.Qual Saf Health Care.2006;15:433436.
  13. Miyakis S, Karamanof G, Liontos M, Mountokalakis T.Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy.Postgrad Med J.2006;82:823829.
  14. Winkens R, Pop P, Grol R, et al.Effects of routine individual feedback over nine years on general practitioners' requests for tests.BMJ.1996;312:490.
  15. Kisuule F, Wright S, Barreto J, Zenilman J.Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach.J Hosp Med.2008;3(1):6470.
  16. Feldman L, Minter‐Jordan M. The role of the medical consultant. Johns Hopkins Consultative Medicine Essentials for Hospitalists. Available at:http://www.jhcme.com/site/article.cfm?ID=8. Accessed April2009.
  17. Hysong S, Best R, Pugh J.Audit and feedback and clinical practice guideline adherence: making feedback actionable.Implement Sci.2006;1:9.
  18. Keely E, Myers K, Dojeiji S, Campbell C.Peer assessment of outpatient consultation letters—feasibility and satisfaction.BMC Med Educ.2007;7:13.
  19. Beckman TJ, Cook DA, Mandrekar JN.What is the validity evidence for assessment of clinical teaching?J Gen Intern Med.2005;20:11591164.
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Journal of Hospital Medicine - 4(8)
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Journal of Hospital Medicine - 4(8)
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A case‐based teaching module combined with audit and feedback to improve the quality of consultations
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A case‐based teaching module combined with audit and feedback to improve the quality of consultations
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