Kelly April Tyrrell

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

In a recent visit to Capitol Hill, Ann Sheehy, MD, MS, FHM, gave Congressional lawmakers the hospitalist perspective on how such Medicare policies as the two-midnight rule, patient observation status, and Recovery Audit Contractor (RAC) program impact patient care, physicians, and hospitals.

These issues are "so important and I am passionate about [them]," says Dr. Sheehy, a physician at the University of Wisconsin School of Medicine and Public Health (UW) in Madison who addressed the House Committee on Ways and Means' Subcommittee on Health on May 20. "I saw what was happening to patients, and it just did not make any sense at all."

Under the Centers for Medicare & Medicaid Service's two-midnight rule, most patients who stay in the hospital fewer than two days must be considered outpatients or under observation.

Observation status leaves them on the hook for the costs of any chronic condition medications they receive in the hospital, and patients under observation, or considered to be outpatients, are not eligible for skilled nursing facility (SNF) care coverage.

"Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals," Dr. Sheehy told the committee in her testimony [PDF].

SHM actively supports the Improving Access to Medicare Coverage Act (H.R. 1179), bipartisan legislation sponsored by Rep. Joe Courtney (D-Conn.), aimed at ensuring Medicare beneficiaries classified under observation are considered inpatient for the purposes of accessing SNF care.

Dr. Sheehy also addressed problems with Medicare's RAC program, telling Congress that "RAC auditors are paid exclusively on contingency as a percent of the Medicare dollars they recover for the federal government on cases audited," according to her testimony. "Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited." She added "hospitals spend an enormous amount of resources on determining patient status, and then preparing cases for audit and appeal, for very little benefit."

At the Congressional hearing, Dr. Sheehy used her experience at UW and findings based on two studies about observation status in hospitals she and colleagues published last year in JAMA Internal Medicine to build a backstory around the issues.

In one of her studies, Dr. Sheehy and colleagues found that nearly half of UW patients would have been assigned observation status rather than inpatient under the two-midnight rule based on their hospital arrival time.

Additionally, Dr. Sheehy told Congress that RAC audits of 299 patient charts at UW found that 21% had improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of May 14.

Dr. Sheehy hopes her testimony will lead to meaningful changes.

"Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it," Dr. Sheehy says. "Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind."

For SHM, Dr. Sheehy's testimony demonstrates that hospitalists are taking leadership roles when it comes to critical issues that impact patients, physicians, and hospitals.

"The hearing shows the strength of hospital medicine as a specialty and a movement in healthcare: hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general," says SHM president Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

"These policy discussions are critical to the care our patients receive," Dr. Kealey adds. "Congress is clearly interested in and listening to the hospitalist perspective. Dr. Sheehy represented the nation's 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty." Th

Visit our website for more information on Medicare's two-midnight rule.

In a recent visit to Capitol Hill, Ann Sheehy, MD, MS, FHM, gave Congressional lawmakers the hospitalist perspective on how such Medicare policies as the two-midnight rule, patient observation status, and Recovery Audit Contractor (RAC) program impact patient care, physicians, and hospitals.

These issues are "so important and I am passionate about [them]," says Dr. Sheehy, a physician at the University of Wisconsin School of Medicine and Public Health (UW) in Madison who addressed the House Committee on Ways and Means' Subcommittee on Health on May 20. "I saw what was happening to patients, and it just did not make any sense at all."

Under the Centers for Medicare & Medicaid Service's two-midnight rule, most patients who stay in the hospital fewer than two days must be considered outpatients or under observation.

Observation status leaves them on the hook for the costs of any chronic condition medications they receive in the hospital, and patients under observation, or considered to be outpatients, are not eligible for skilled nursing facility (SNF) care coverage.

"Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals," Dr. Sheehy told the committee in her testimony [PDF].

SHM actively supports the Improving Access to Medicare Coverage Act (H.R. 1179), bipartisan legislation sponsored by Rep. Joe Courtney (D-Conn.), aimed at ensuring Medicare beneficiaries classified under observation are considered inpatient for the purposes of accessing SNF care.

Dr. Sheehy also addressed problems with Medicare's RAC program, telling Congress that "RAC auditors are paid exclusively on contingency as a percent of the Medicare dollars they recover for the federal government on cases audited," according to her testimony. "Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited." She added "hospitals spend an enormous amount of resources on determining patient status, and then preparing cases for audit and appeal, for very little benefit."

At the Congressional hearing, Dr. Sheehy used her experience at UW and findings based on two studies about observation status in hospitals she and colleagues published last year in JAMA Internal Medicine to build a backstory around the issues.

In one of her studies, Dr. Sheehy and colleagues found that nearly half of UW patients would have been assigned observation status rather than inpatient under the two-midnight rule based on their hospital arrival time.

Additionally, Dr. Sheehy told Congress that RAC audits of 299 patient charts at UW found that 21% had improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of May 14.

Dr. Sheehy hopes her testimony will lead to meaningful changes.

"Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it," Dr. Sheehy says. "Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind."

For SHM, Dr. Sheehy's testimony demonstrates that hospitalists are taking leadership roles when it comes to critical issues that impact patients, physicians, and hospitals.

"The hearing shows the strength of hospital medicine as a specialty and a movement in healthcare: hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general," says SHM president Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

"These policy discussions are critical to the care our patients receive," Dr. Kealey adds. "Congress is clearly interested in and listening to the hospitalist perspective. Dr. Sheehy represented the nation's 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty." Th

Visit our website for more information on Medicare's two-midnight rule.

In a recent visit to Capitol Hill, Ann Sheehy, MD, MS, FHM, gave Congressional lawmakers the hospitalist perspective on how such Medicare policies as the two-midnight rule, patient observation status, and Recovery Audit Contractor (RAC) program impact patient care, physicians, and hospitals.

These issues are "so important and I am passionate about [them]," says Dr. Sheehy, a physician at the University of Wisconsin School of Medicine and Public Health (UW) in Madison who addressed the House Committee on Ways and Means' Subcommittee on Health on May 20. "I saw what was happening to patients, and it just did not make any sense at all."

Under the Centers for Medicare & Medicaid Service's two-midnight rule, most patients who stay in the hospital fewer than two days must be considered outpatients or under observation.

Observation status leaves them on the hook for the costs of any chronic condition medications they receive in the hospital, and patients under observation, or considered to be outpatients, are not eligible for skilled nursing facility (SNF) care coverage.

"Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals," Dr. Sheehy told the committee in her testimony [PDF].

SHM actively supports the Improving Access to Medicare Coverage Act (H.R. 1179), bipartisan legislation sponsored by Rep. Joe Courtney (D-Conn.), aimed at ensuring Medicare beneficiaries classified under observation are considered inpatient for the purposes of accessing SNF care.

Dr. Sheehy also addressed problems with Medicare's RAC program, telling Congress that "RAC auditors are paid exclusively on contingency as a percent of the Medicare dollars they recover for the federal government on cases audited," according to her testimony. "Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited." She added "hospitals spend an enormous amount of resources on determining patient status, and then preparing cases for audit and appeal, for very little benefit."

At the Congressional hearing, Dr. Sheehy used her experience at UW and findings based on two studies about observation status in hospitals she and colleagues published last year in JAMA Internal Medicine to build a backstory around the issues.

In one of her studies, Dr. Sheehy and colleagues found that nearly half of UW patients would have been assigned observation status rather than inpatient under the two-midnight rule based on their hospital arrival time.

Additionally, Dr. Sheehy told Congress that RAC audits of 299 patient charts at UW found that 21% had improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of May 14.

Dr. Sheehy hopes her testimony will lead to meaningful changes.

"Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it," Dr. Sheehy says. "Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind."

For SHM, Dr. Sheehy's testimony demonstrates that hospitalists are taking leadership roles when it comes to critical issues that impact patients, physicians, and hospitals.

"The hearing shows the strength of hospital medicine as a specialty and a movement in healthcare: hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general," says SHM president Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

"These policy discussions are critical to the care our patients receive," Dr. Kealey adds. "Congress is clearly interested in and listening to the hospitalist perspective. Dr. Sheehy represented the nation's 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty." Th

Visit our website for more information on Medicare's two-midnight rule.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).

“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.

Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).

“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.

In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.

For Comparison’s Sake

For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.

Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.

If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.

New Brand, New Push

PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.

This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.

In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.

The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.

“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.

Moving Forward

In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).

Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.

“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”

Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.

Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.

“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.

Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.

“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).

“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.

Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).

“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.

In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.

For Comparison’s Sake

For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.

Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.

If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.

New Brand, New Push

PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.

This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.

In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.

The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.

“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.

Moving Forward

In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).

Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.

“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”

Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.

Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.

“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.

Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.

“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).

“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.

Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).

“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.

In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.

For Comparison’s Sake

For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.

Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.

If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.

New Brand, New Push

PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.

This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.

In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.

The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.

“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.

Moving Forward

In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).

Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.

“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”

Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.

Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.

“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.

Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.

“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”

Kelly April Tyrrell is a freelance writer in Wilmington, Del.