List offers opportunities to improve value in hospital medicine

Recommendations from the Right Care Alliance Hospital Medicine Council include checking orthostatic vital signs in patients with syncope before considering testing beyond an electrocardiogram.


A group of clinicians and patient advocates recently collaborated on a list of overuse and underuse opportunities to improve care value in hospital medicine.

Physicians, advanced practitioners, and nurses in the Right Care Alliance (RCA) Hospital Medicine Council worked with patient advocates from the RCA Community Engagement Council to develop five “do's” and five “don'ts” in hospital medicine. They used a framework that required items on the list to matter to patients, to be evidence-based, to be infractions of value-focused care, and to have high potential to harm or benefit. The list was published online March 1 by the Journal of General Internal Medicine.

The recommendations focusing on underuse, or the “do's,” include recommendations on implementing programs to promote sleep in the inpatient setting, communicating with the patient's primary care physician prior to dismissal, providing personalized instructions to patients at the time of dismissal, checking orthostatic vital signs in patients with syncope before considering testing beyond an electrocardiogram, and using structured verbal and written communication for shift and service handoffs between clinicians.

The recommendations focusing on overuse, or the “don'ts,” include recommendations against ordering daily labs in patients who are clinically stable or in the absence of a specific clinical question, ordering telemetry monitoring without a specific clinical indication, and routinely ordering laboratory and imaging tests before evaluating and examining the patient.

The authors stressed the importance of an approach to improving health care value that considers input from both patients and physicians and focuses on both underuse and overuse rather than solely the latter. “Optimizing care on both ends of the utilization spectrum has the greatest potential to improve acceptance and uptake in the clinical setting,” they wrote. “This collaborative, patient-oriented process can set an example for future high-value lists.”