Candace Mitchell

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How much are insured nonelderly adult patients paying out of pocket for inpatient care, and does that amount vary over time or by patient characteristics, region, or type of insurance?

Background: Prior estimates have been based on patient-reported survey data. This is the first study to find nationwide out-of-pocket expenditure for inpatient hospitalizations.

Study Design: Retrospective analysis.

Setting: Medical claims data from Aetna, UnitedHealthcare, and Humana including 7.3 million hospitalizations from 2009 to 2013.

Synopsis: Authors used the Health Care Cost Institute (HCCI) database and studied inpatient hospitalization for ages 18–64. The adjusted total cost sharing per inpatient hospitalization increased by 37% (from $738 in 2009 to $1,013 in 2013). Both the mean amount of coinsurance and deductibles increased during this period by 33% (from $518 to $688) and 86% (from $145 to $270), respectively. The mean copayment decreased by 27% (from $75 to $55).

Increase in cost sharing was lowest in individual-market and consumer-directed health plans, although both had highest cost sharing.

Total cost sharing increased in every state. The largest increases were seen in Georgia, Louisiana, and Colorado. In 2013, the states with the highest cost sharing were Utah, Alaska, and Oregon.

Acute myocardial infarction and acute appendicitis saw maximum rise in out-of-pocket spending; both surpassed $1,500 in 2013. Cost sharing associated with procedures was lower.

Bottom Line: Even after adjusting for inflation and case-mix differences, the total cost sharing per inpatient hospitalization increased between 2009 and 2013. Policymakers and patients need to pay attention to these trends.

Citation: Adrion ER, Ryan AM, Seltzer AC, Chen LM, Ayanian JZ, Nallamothu BK. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176(9)1325-1332.

Short Take

Aspirin Is Being Used Instead of Anticoagulation in Afib

Despite recommendations to anticoagulate patients with CHADS2 /CHA2DS2-VASc scores of ≥2, more than one-third of the patients in a large population of cardiology outpatients were treated with aspirin alone.

Citation: Hsu JC, Maddox TM, Kennedy K, et al. Aspirin instead of oral anticoagulant prescription in atrial fibrillation patients at risk for stroke. J Am Coll Cardiol. 2016;67(25):2913-2923.

Clinical Question: How much are insured nonelderly adult patients paying out of pocket for inpatient care, and does that amount vary over time or by patient characteristics, region, or type of insurance?

Background: Prior estimates have been based on patient-reported survey data. This is the first study to find nationwide out-of-pocket expenditure for inpatient hospitalizations.

Study Design: Retrospective analysis.

Setting: Medical claims data from Aetna, UnitedHealthcare, and Humana including 7.3 million hospitalizations from 2009 to 2013.

Synopsis: Authors used the Health Care Cost Institute (HCCI) database and studied inpatient hospitalization for ages 18–64. The adjusted total cost sharing per inpatient hospitalization increased by 37% (from $738 in 2009 to $1,013 in 2013). Both the mean amount of coinsurance and deductibles increased during this period by 33% (from $518 to $688) and 86% (from $145 to $270), respectively. The mean copayment decreased by 27% (from $75 to $55).

Increase in cost sharing was lowest in individual-market and consumer-directed health plans, although both had highest cost sharing.

Total cost sharing increased in every state. The largest increases were seen in Georgia, Louisiana, and Colorado. In 2013, the states with the highest cost sharing were Utah, Alaska, and Oregon.

Acute myocardial infarction and acute appendicitis saw maximum rise in out-of-pocket spending; both surpassed $1,500 in 2013. Cost sharing associated with procedures was lower.

Bottom Line: Even after adjusting for inflation and case-mix differences, the total cost sharing per inpatient hospitalization increased between 2009 and 2013. Policymakers and patients need to pay attention to these trends.

Citation: Adrion ER, Ryan AM, Seltzer AC, Chen LM, Ayanian JZ, Nallamothu BK. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176(9)1325-1332.

Short Take

Aspirin Is Being Used Instead of Anticoagulation in Afib

Despite recommendations to anticoagulate patients with CHADS2 /CHA2DS2-VASc scores of ≥2, more than one-third of the patients in a large population of cardiology outpatients were treated with aspirin alone.

Citation: Hsu JC, Maddox TM, Kennedy K, et al. Aspirin instead of oral anticoagulant prescription in atrial fibrillation patients at risk for stroke. J Am Coll Cardiol. 2016;67(25):2913-2923.

Clinical Question: How much are insured nonelderly adult patients paying out of pocket for inpatient care, and does that amount vary over time or by patient characteristics, region, or type of insurance?

Background: Prior estimates have been based on patient-reported survey data. This is the first study to find nationwide out-of-pocket expenditure for inpatient hospitalizations.

Study Design: Retrospective analysis.

Setting: Medical claims data from Aetna, UnitedHealthcare, and Humana including 7.3 million hospitalizations from 2009 to 2013.

Synopsis: Authors used the Health Care Cost Institute (HCCI) database and studied inpatient hospitalization for ages 18–64. The adjusted total cost sharing per inpatient hospitalization increased by 37% (from $738 in 2009 to $1,013 in 2013). Both the mean amount of coinsurance and deductibles increased during this period by 33% (from $518 to $688) and 86% (from $145 to $270), respectively. The mean copayment decreased by 27% (from $75 to $55).

Increase in cost sharing was lowest in individual-market and consumer-directed health plans, although both had highest cost sharing.

Total cost sharing increased in every state. The largest increases were seen in Georgia, Louisiana, and Colorado. In 2013, the states with the highest cost sharing were Utah, Alaska, and Oregon.

Acute myocardial infarction and acute appendicitis saw maximum rise in out-of-pocket spending; both surpassed $1,500 in 2013. Cost sharing associated with procedures was lower.

Bottom Line: Even after adjusting for inflation and case-mix differences, the total cost sharing per inpatient hospitalization increased between 2009 and 2013. Policymakers and patients need to pay attention to these trends.

Citation: Adrion ER, Ryan AM, Seltzer AC, Chen LM, Ayanian JZ, Nallamothu BK. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176(9)1325-1332.

Short Take

Aspirin Is Being Used Instead of Anticoagulation in Afib

Despite recommendations to anticoagulate patients with CHADS2 /CHA2DS2-VASc scores of ≥2, more than one-third of the patients in a large population of cardiology outpatients were treated with aspirin alone.

Citation: Hsu JC, Maddox TM, Kennedy K, et al. Aspirin instead of oral anticoagulant prescription in atrial fibrillation patients at risk for stroke. J Am Coll Cardiol. 2016;67(25):2913-2923.

The State of Hospital Medicine Report (SoHM) is the most comprehensive survey of hospital medicine in the country and provides current data on hospitalist compensation and production as well as covers practice demographics, staffing levels, staff growth, and compensation models. This year, the survey covers several new topics, including:

• The percentage of the hospital’s total patient volume (for the population the group serves, i.e., adult versus children versus both) that the hospital medicine group (HMG) was responsible for caring for
• The presence of medical hospitalists within the HMG focusing their practice on a specific medical subspecialty, such as critical care, neurology, or oncology
• The value of CME allowances for hospitalists
• The utilization of prolonged service codes by hospitalists
• Charge capture methodologies being used by HMGs
• For academic HMGs, the dollar amount of financial support provided for non-clinical work

Order your copy now and improve your practice today at www.hospitalmedicine.org/survey.

The State of Hospital Medicine Report (SoHM) is the most comprehensive survey of hospital medicine in the country and provides current data on hospitalist compensation and production as well as covers practice demographics, staffing levels, staff growth, and compensation models. This year, the survey covers several new topics, including:

• The percentage of the hospital’s total patient volume (for the population the group serves, i.e., adult versus children versus both) that the hospital medicine group (HMG) was responsible for caring for
• The presence of medical hospitalists within the HMG focusing their practice on a specific medical subspecialty, such as critical care, neurology, or oncology
• The value of CME allowances for hospitalists
• The utilization of prolonged service codes by hospitalists
• Charge capture methodologies being used by HMGs
• For academic HMGs, the dollar amount of financial support provided for non-clinical work

Order your copy now and improve your practice today at www.hospitalmedicine.org/survey.

The State of Hospital Medicine Report (SoHM) is the most comprehensive survey of hospital medicine in the country and provides current data on hospitalist compensation and production as well as covers practice demographics, staffing levels, staff growth, and compensation models. This year, the survey covers several new topics, including:

• The percentage of the hospital’s total patient volume (for the population the group serves, i.e., adult versus children versus both) that the hospital medicine group (HMG) was responsible for caring for
• The presence of medical hospitalists within the HMG focusing their practice on a specific medical subspecialty, such as critical care, neurology, or oncology
• The value of CME allowances for hospitalists
• The utilization of prolonged service codes by hospitalists
• Charge capture methodologies being used by HMGs
• For academic HMGs, the dollar amount of financial support provided for non-clinical work

Order your copy now and improve your practice today at www.hospitalmedicine.org/survey.

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

---

Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

---

Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

---

Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

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Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

---

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

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Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

A recent Journal of Hospital Medicine study found that most hospitalists do not believe they should be involved in breast cancer screening for their hospitalized patients who are overdue for a screening.

Study authors at Johns Hopkins Bayview (JHB) Medical Center in Baltimore surveyed nearly 100 hospitalists about their thoughts on ordering a mammography for hospitalized women and possible concerns for hospitalists ordering inpatient screenings. Only 38% of those surveyed believed that hospitalists should be involved with breast cancer screening. The main concerns, according to survey takers, were following up on the results of the screening and that the mammography might not be covered by patients’ insurance.

The Hospitalist caught up with lead author Waseem Khaliq MD, MPH, who is a hospitalist and assistant professor of medicine at Johns Hopkins School of Medicine and a member of the JHB Cancer Committee.

Question: What are the key takeaways from this study?

Answer: About three years ago, we looked up what the adherence rate is among women who are admitted to the hospital for breast cancer screenings, and what we found was that a lot of these women were nonadherent to the breast cancer screening. So we polled those women who were nonadherent to the breast cancer screening and asked, “What if we were able to offer you a mammogram while you were in the hospital for other issues?” About 76% said that they would like to have a mammogram while they were in the hospital.

Looking at that background, we polled this question to our hospitalists, too. What we found out was that a lot of the hospitalists were not willing to order a mammogram or were not too excited about getting a breast cancer screening done in the hospital setting. A majority told us that they’re more worried about how those results are going to be followed up, and it is possible that even if they order this mammogram that it may interfere with patient care or patient discharge. Then who would cover the cost of the mammogram if they do it in the inpatient setting?

So although a third of the hospitalists would still order a mammogram for those women who were high risk … a majority of them were not willing to because there were some perceived barriers to that.

Q: What is your reaction to the concerns with screening inpatients?

A: I can understand the concerns that most of the hospitalists have in regard to screening every patient that comes to the hospital. What I think we can do is, at the very least, we can be smart enough to figure out if a patient were at high risk for developing cancer and at least have those patients who were at high risk get screened.

Q: Where do you think hospitalists should go from here with regard to their patients who are overdue for breast cancer screenings?

A: We need to test for the feasibility and the financial issue of actually getting a screening mammogram in the hospital setting. I think down the road it should not matter what setting a patient [intersects] with the health system; it could be inpatient or outpatient. Patients should be provided the care and prevention needs that are recommended for their routine care. The next step should be doing a feasibility study, looking at whether or not these mammograms can be done in the hospital setting and do not interfere with the patient’s acute care. TH

Candace Mitchell is a freelance writer in New Jersey.

A recent Journal of Hospital Medicine study found that most hospitalists do not believe they should be involved in breast cancer screening for their hospitalized patients who are overdue for a screening.

Study authors at Johns Hopkins Bayview (JHB) Medical Center in Baltimore surveyed nearly 100 hospitalists about their thoughts on ordering a mammography for hospitalized women and possible concerns for hospitalists ordering inpatient screenings. Only 38% of those surveyed believed that hospitalists should be involved with breast cancer screening. The main concerns, according to survey takers, were following up on the results of the screening and that the mammography might not be covered by patients’ insurance.

The Hospitalist caught up with lead author Waseem Khaliq MD, MPH, who is a hospitalist and assistant professor of medicine at Johns Hopkins School of Medicine and a member of the JHB Cancer Committee.

Question: What are the key takeaways from this study?

Answer: About three years ago, we looked up what the adherence rate is among women who are admitted to the hospital for breast cancer screenings, and what we found was that a lot of these women were nonadherent to the breast cancer screening. So we polled those women who were nonadherent to the breast cancer screening and asked, “What if we were able to offer you a mammogram while you were in the hospital for other issues?” About 76% said that they would like to have a mammogram while they were in the hospital.

Looking at that background, we polled this question to our hospitalists, too. What we found out was that a lot of the hospitalists were not willing to order a mammogram or were not too excited about getting a breast cancer screening done in the hospital setting. A majority told us that they’re more worried about how those results are going to be followed up, and it is possible that even if they order this mammogram that it may interfere with patient care or patient discharge. Then who would cover the cost of the mammogram if they do it in the inpatient setting?

So although a third of the hospitalists would still order a mammogram for those women who were high risk … a majority of them were not willing to because there were some perceived barriers to that.

Q: What is your reaction to the concerns with screening inpatients?

A: I can understand the concerns that most of the hospitalists have in regard to screening every patient that comes to the hospital. What I think we can do is, at the very least, we can be smart enough to figure out if a patient were at high risk for developing cancer and at least have those patients who were at high risk get screened.

Q: Where do you think hospitalists should go from here with regard to their patients who are overdue for breast cancer screenings?

A: We need to test for the feasibility and the financial issue of actually getting a screening mammogram in the hospital setting. I think down the road it should not matter what setting a patient [intersects] with the health system; it could be inpatient or outpatient. Patients should be provided the care and prevention needs that are recommended for their routine care. The next step should be doing a feasibility study, looking at whether or not these mammograms can be done in the hospital setting and do not interfere with the patient’s acute care. TH

Candace Mitchell is a freelance writer in New Jersey.

A recent Journal of Hospital Medicine study found that most hospitalists do not believe they should be involved in breast cancer screening for their hospitalized patients who are overdue for a screening.

Study authors at Johns Hopkins Bayview (JHB) Medical Center in Baltimore surveyed nearly 100 hospitalists about their thoughts on ordering a mammography for hospitalized women and possible concerns for hospitalists ordering inpatient screenings. Only 38% of those surveyed believed that hospitalists should be involved with breast cancer screening. The main concerns, according to survey takers, were following up on the results of the screening and that the mammography might not be covered by patients’ insurance.

The Hospitalist caught up with lead author Waseem Khaliq MD, MPH, who is a hospitalist and assistant professor of medicine at Johns Hopkins School of Medicine and a member of the JHB Cancer Committee.

Question: What are the key takeaways from this study?

Answer: About three years ago, we looked up what the adherence rate is among women who are admitted to the hospital for breast cancer screenings, and what we found was that a lot of these women were nonadherent to the breast cancer screening. So we polled those women who were nonadherent to the breast cancer screening and asked, “What if we were able to offer you a mammogram while you were in the hospital for other issues?” About 76% said that they would like to have a mammogram while they were in the hospital.

Looking at that background, we polled this question to our hospitalists, too. What we found out was that a lot of the hospitalists were not willing to order a mammogram or were not too excited about getting a breast cancer screening done in the hospital setting. A majority told us that they’re more worried about how those results are going to be followed up, and it is possible that even if they order this mammogram that it may interfere with patient care or patient discharge. Then who would cover the cost of the mammogram if they do it in the inpatient setting?

So although a third of the hospitalists would still order a mammogram for those women who were high risk … a majority of them were not willing to because there were some perceived barriers to that.

Q: What is your reaction to the concerns with screening inpatients?

A: I can understand the concerns that most of the hospitalists have in regard to screening every patient that comes to the hospital. What I think we can do is, at the very least, we can be smart enough to figure out if a patient were at high risk for developing cancer and at least have those patients who were at high risk get screened.

Q: Where do you think hospitalists should go from here with regard to their patients who are overdue for breast cancer screenings?

A: We need to test for the feasibility and the financial issue of actually getting a screening mammogram in the hospital setting. I think down the road it should not matter what setting a patient [intersects] with the health system; it could be inpatient or outpatient. Patients should be provided the care and prevention needs that are recommended for their routine care. The next step should be doing a feasibility study, looking at whether or not these mammograms can be done in the hospital setting and do not interfere with the patient’s acute care. TH

Candace Mitchell is a freelance writer in New Jersey.

Photographs from Hospital Medicine 2015, which took place March 29-April 1 at the Gaylord National Hotel and Conference Center in National Harbor, Md.

Photos by Manuel Noguera

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Photographs from Hospital Medicine 2015, which took place March 29-April 1 at the Gaylord National Hotel and Conference Center in National Harbor, Md.

Photos by Manuel Noguera

[gallery ids="9197,9196,9195,9194,9193,9192,9191,9190,9189,9188,9187,9186,9185,9184,9183,9182,9181,9180,9179,9178,9177,9176,9175,9171"]

Photographs from Hospital Medicine 2015, which took place March 29-April 1 at the Gaylord National Hotel and Conference Center in National Harbor, Md.

Photos by Manuel Noguera

[gallery ids="9197,9196,9195,9194,9193,9192,9191,9190,9189,9188,9187,9186,9185,9184,9183,9182,9181,9180,9179,9178,9177,9176,9175,9171"]

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

 

Visit our website for more information on hospital ratings.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

 

Visit our website for more information on hospital ratings.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

 

Visit our website for more information on hospital ratings.

Hospitalists need not fear negative consequences when prescribing guideline-recommended antibiotic therapy for children hospitalized with community-acquired pneumonia (CAP), according to a recent study conducted at Cincinnati Children’s Hospital Medical Center (CCHMC).

"Guideline-recommended therapy for pediatric pneumonia did not result in different outcomes than nonrecommended [largely cephalosporin] therapy," lead author and CCHMC-based hospitalist Joanna Thomson MD, MPH, says in an email to The Hospitalist.

Published in the Journal of Hospital Medicine, the study followed the outcomes of 168 pediatric inpatients ages 3 months to 18 years who were prescribed empiric guideline-recommended therapy, which advises using an aminopenicillin first rather than a broad-spectrum antibiotic. The study focused on patients’ outcomes, specifically length of stay (LOS), total cost of hospitalization, and inpatient pharmacy costs, and found no difference in LOS or costs for patients treated according to guidelines compared with those whose treatment varied from the recommendations.

"Given growing concerns regarding antimicrobial resistance, it is pretty easy to extrapolate the benefits of using narrow-spectrum therapy, but we wanted to make sure that it wasn't resulting in negative unintended consequences," Dr. Thomson says. "Indeed, use of guideline-recommended therapy did not change our outcomes."

However, most patients hospitalized with CAP do not currently receive guideline-recommended therapy, according to Dr. Thomson. CCHMC had been one of those institutions overprescribing cephalosporin, with nearly 70% of children admitted with pneumonia receiving the antibiotic. That practice has since changed, she notes.

"The majority of hospitalized patients in the U.S. still receive broad-spectrum cephalosporins," Dr. Thomson says. "I suspect that this may partially be due to fears of unintended negative consequences. We should all be good stewards and prescribe guideline-recommended therapy whenever possible."

Visit our website for more information on antibiotic prescription practices.

Hospitalists need not fear negative consequences when prescribing guideline-recommended antibiotic therapy for children hospitalized with community-acquired pneumonia (CAP), according to a recent study conducted at Cincinnati Children’s Hospital Medical Center (CCHMC).

"Guideline-recommended therapy for pediatric pneumonia did not result in different outcomes than nonrecommended [largely cephalosporin] therapy," lead author and CCHMC-based hospitalist Joanna Thomson MD, MPH, says in an email to The Hospitalist.

Published in the Journal of Hospital Medicine, the study followed the outcomes of 168 pediatric inpatients ages 3 months to 18 years who were prescribed empiric guideline-recommended therapy, which advises using an aminopenicillin first rather than a broad-spectrum antibiotic. The study focused on patients’ outcomes, specifically length of stay (LOS), total cost of hospitalization, and inpatient pharmacy costs, and found no difference in LOS or costs for patients treated according to guidelines compared with those whose treatment varied from the recommendations.

"Given growing concerns regarding antimicrobial resistance, it is pretty easy to extrapolate the benefits of using narrow-spectrum therapy, but we wanted to make sure that it wasn't resulting in negative unintended consequences," Dr. Thomson says. "Indeed, use of guideline-recommended therapy did not change our outcomes."

However, most patients hospitalized with CAP do not currently receive guideline-recommended therapy, according to Dr. Thomson. CCHMC had been one of those institutions overprescribing cephalosporin, with nearly 70% of children admitted with pneumonia receiving the antibiotic. That practice has since changed, she notes.

"The majority of hospitalized patients in the U.S. still receive broad-spectrum cephalosporins," Dr. Thomson says. "I suspect that this may partially be due to fears of unintended negative consequences. We should all be good stewards and prescribe guideline-recommended therapy whenever possible."

Visit our website for more information on antibiotic prescription practices.

Hospitalists need not fear negative consequences when prescribing guideline-recommended antibiotic therapy for children hospitalized with community-acquired pneumonia (CAP), according to a recent study conducted at Cincinnati Children’s Hospital Medical Center (CCHMC).

"Guideline-recommended therapy for pediatric pneumonia did not result in different outcomes than nonrecommended [largely cephalosporin] therapy," lead author and CCHMC-based hospitalist Joanna Thomson MD, MPH, says in an email to The Hospitalist.

Published in the Journal of Hospital Medicine, the study followed the outcomes of 168 pediatric inpatients ages 3 months to 18 years who were prescribed empiric guideline-recommended therapy, which advises using an aminopenicillin first rather than a broad-spectrum antibiotic. The study focused on patients’ outcomes, specifically length of stay (LOS), total cost of hospitalization, and inpatient pharmacy costs, and found no difference in LOS or costs for patients treated according to guidelines compared with those whose treatment varied from the recommendations.

"Given growing concerns regarding antimicrobial resistance, it is pretty easy to extrapolate the benefits of using narrow-spectrum therapy, but we wanted to make sure that it wasn't resulting in negative unintended consequences," Dr. Thomson says. "Indeed, use of guideline-recommended therapy did not change our outcomes."

However, most patients hospitalized with CAP do not currently receive guideline-recommended therapy, according to Dr. Thomson. CCHMC had been one of those institutions overprescribing cephalosporin, with nearly 70% of children admitted with pneumonia receiving the antibiotic. That practice has since changed, she notes.

"The majority of hospitalized patients in the U.S. still receive broad-spectrum cephalosporins," Dr. Thomson says. "I suspect that this may partially be due to fears of unintended negative consequences. We should all be good stewards and prescribe guideline-recommended therapy whenever possible."

Visit our website for more information on antibiotic prescription practices.