Quality

Presenter

Leonard Feldman, MD, SFHM

Session summary

In the current climate of increasing national health care expenditures, the Journal of Hospital Medicine continues to expand its series “Things We Do for No Reason” to shed light on areas for improvement in the delivery of high-value care. Physicians, however, continue to practice low value care because of practice habits and lack of cost transparency. In keeping with the spirit of the journal’s series, three low-value practices were highlighted in this HM18 session, including the benefits of high-flow nasal cannula (HFNC) oxygen therapy, the value of serum albumin and prealbumin in malnutrition, and the use of nebulized versus inhaler albuterol.

HFNC oxygen therapy has become a widespread practice internationally, with large variations in implementation across all age ranges. In bronchiolitic infants, variations in time of implementation, duration of therapy, weaning policies, and outcome measures have yielded mixed results to date. Many studies are still underway, but current literature has not shown significant benefits of starting HFNC early in the illness process, and infants receiving HFNC have not had better outcomes than those who received standard therapy (low-flow nasal cannula).

Serum albumin and prealbumin are often cited as markers of malnutrition. In patients on tube feeds, such as those with cerebral palsy and complex medical conditions, current literature shows no benefit in the use of these lab markers for screening or for following to assess improvement. In addition, patients with eating disorders do not have significant correlation of their nutritive status with these markers. Therefore, the use of these labs for screening of malnutrition is of little if any value.

Finally, when comparing albuterol delivery systems, there has been no proof that nebulized albuterol is any better than metered dose inhalers (MDI) in its effect. As long as appropriate dosing of MDIs is done, the benefits are the same. In addition, side effects are fewer, and the length of stay in the ED is shorter. The more a family uses MDI inhalers, the better their technique. Studies have shown it takes approximately three attempts at using an MDI to get the technique correct, so inpatient MDI use would also decrease user error in the outpatient setting.
 

Key takeaways for HM

• Practice habits, lack of transparency of costs, and regional training lead to low value care practices.
• Early introduction of high-flow nasal cannula in hospitalization of an infant with bronchiolitis has not been shown to decrease length of stay or severity outcomes, according to currently available data.
• Serum albumin and prealbumin have little to no benefit in screening of malnutrition.
• Nebulized albuterol has not been proven to be more beneficial that MDI albuterol at appropriate doses.
• Repeat MDI administration has been shown to positively affect user administration techniques.
• MDI albuterol use has fewer side effects and decreased ED length of stay, compared with nebulized albuterol.

Dr. Schwenk is an associate professor of pediatrics at the University of Louisville (Ky.) and a pediatric hospitalist at Norton Children’s Hospital, Louisville.

Presenter

Leonard Feldman, MD, SFHM

Session summary

In the current climate of increasing national health care expenditures, the Journal of Hospital Medicine continues to expand its series “Things We Do for No Reason” to shed light on areas for improvement in the delivery of high-value care. Physicians, however, continue to practice low value care because of practice habits and lack of cost transparency. In keeping with the spirit of the journal’s series, three low-value practices were highlighted in this HM18 session, including the benefits of high-flow nasal cannula (HFNC) oxygen therapy, the value of serum albumin and prealbumin in malnutrition, and the use of nebulized versus inhaler albuterol.

HFNC oxygen therapy has become a widespread practice internationally, with large variations in implementation across all age ranges. In bronchiolitic infants, variations in time of implementation, duration of therapy, weaning policies, and outcome measures have yielded mixed results to date. Many studies are still underway, but current literature has not shown significant benefits of starting HFNC early in the illness process, and infants receiving HFNC have not had better outcomes than those who received standard therapy (low-flow nasal cannula).

Serum albumin and prealbumin are often cited as markers of malnutrition. In patients on tube feeds, such as those with cerebral palsy and complex medical conditions, current literature shows no benefit in the use of these lab markers for screening or for following to assess improvement. In addition, patients with eating disorders do not have significant correlation of their nutritive status with these markers. Therefore, the use of these labs for screening of malnutrition is of little if any value.

Finally, when comparing albuterol delivery systems, there has been no proof that nebulized albuterol is any better than metered dose inhalers (MDI) in its effect. As long as appropriate dosing of MDIs is done, the benefits are the same. In addition, side effects are fewer, and the length of stay in the ED is shorter. The more a family uses MDI inhalers, the better their technique. Studies have shown it takes approximately three attempts at using an MDI to get the technique correct, so inpatient MDI use would also decrease user error in the outpatient setting.
 

Key takeaways for HM

• Practice habits, lack of transparency of costs, and regional training lead to low value care practices.
• Early introduction of high-flow nasal cannula in hospitalization of an infant with bronchiolitis has not been shown to decrease length of stay or severity outcomes, according to currently available data.
• Serum albumin and prealbumin have little to no benefit in screening of malnutrition.
• Nebulized albuterol has not been proven to be more beneficial that MDI albuterol at appropriate doses.
• Repeat MDI administration has been shown to positively affect user administration techniques.
• MDI albuterol use has fewer side effects and decreased ED length of stay, compared with nebulized albuterol.

Dr. Schwenk is an associate professor of pediatrics at the University of Louisville (Ky.) and a pediatric hospitalist at Norton Children’s Hospital, Louisville.

Presenter

Leonard Feldman, MD, SFHM

Session summary

In the current climate of increasing national health care expenditures, the Journal of Hospital Medicine continues to expand its series “Things We Do for No Reason” to shed light on areas for improvement in the delivery of high-value care. Physicians, however, continue to practice low value care because of practice habits and lack of cost transparency. In keeping with the spirit of the journal’s series, three low-value practices were highlighted in this HM18 session, including the benefits of high-flow nasal cannula (HFNC) oxygen therapy, the value of serum albumin and prealbumin in malnutrition, and the use of nebulized versus inhaler albuterol.

HFNC oxygen therapy has become a widespread practice internationally, with large variations in implementation across all age ranges. In bronchiolitic infants, variations in time of implementation, duration of therapy, weaning policies, and outcome measures have yielded mixed results to date. Many studies are still underway, but current literature has not shown significant benefits of starting HFNC early in the illness process, and infants receiving HFNC have not had better outcomes than those who received standard therapy (low-flow nasal cannula).

Serum albumin and prealbumin are often cited as markers of malnutrition. In patients on tube feeds, such as those with cerebral palsy and complex medical conditions, current literature shows no benefit in the use of these lab markers for screening or for following to assess improvement. In addition, patients with eating disorders do not have significant correlation of their nutritive status with these markers. Therefore, the use of these labs for screening of malnutrition is of little if any value.

Finally, when comparing albuterol delivery systems, there has been no proof that nebulized albuterol is any better than metered dose inhalers (MDI) in its effect. As long as appropriate dosing of MDIs is done, the benefits are the same. In addition, side effects are fewer, and the length of stay in the ED is shorter. The more a family uses MDI inhalers, the better their technique. Studies have shown it takes approximately three attempts at using an MDI to get the technique correct, so inpatient MDI use would also decrease user error in the outpatient setting.
 

Key takeaways for HM

• Practice habits, lack of transparency of costs, and regional training lead to low value care practices.
• Early introduction of high-flow nasal cannula in hospitalization of an infant with bronchiolitis has not been shown to decrease length of stay or severity outcomes, according to currently available data.
• Serum albumin and prealbumin have little to no benefit in screening of malnutrition.
• Nebulized albuterol has not been proven to be more beneficial that MDI albuterol at appropriate doses.
• Repeat MDI administration has been shown to positively affect user administration techniques.
• MDI albuterol use has fewer side effects and decreased ED length of stay, compared with nebulized albuterol.

Dr. Schwenk is an associate professor of pediatrics at the University of Louisville (Ky.) and a pediatric hospitalist at Norton Children’s Hospital, Louisville.

Hospitalists are key players in improving hospital performance, but they may be overlooking a leading cause of morbidity and mortality, especially among older adults.

Research suggests that at the time of hospital admission, some 20%-50% of all patients are at risk for malnutrition or are malnourished, but only 7% of those patients are diagnosed during their stay, according to research cited in an abstract presented at HM17.¹

“Because individuals who are malnourished lack sufficient nutrients to promote healing and rehabilitation, and are at increased risk of medical complications, it can have a serious impact on patient safety indicators, such as rates of pressure ulcers, wound healing, and risk of falls,” said lead author Eleanor Fitall of Avalere Health. “Early identification and subsequent treatment of these patients is the best way to prevent this risk.”

To address the issue, Avalere Health and the Academy of Nutrition and Dietetics established the Malnutrition Quality Improvement Initiative (MQii), a multi-stakeholder effort to identify tools to support hospital-based care teams in improving malnutrition care quality. They developed a malnutrition Toolkit, which was piloted in 2016 and was shown to effectively improve malnutrition care.

“Since the poster presentation in May, we have successfully implemented the Toolkit at 50 hospitals via a multi-hospital Learning Collaborative,” Ms. Fitall said. They are now recruiting hospitals and health systems to participate in an expanded Learning Collaborative. Interested sites should contact the MQii team at MalnutritionQuality@avalere.com.

“By supporting efforts to improve malnutrition care in the inpatient setting, hospitalists can help reduce the incidence of these problems as well as decrease rates of readmissions and reduce patient lengths of stay,” Ms. Fitall said. “Hospitalists are critical to addressing malnutrition care gaps in the hospital. Dietitians that have undertaken malnutrition quality improvement projects using the MQii Toolkit have found that they are most successful when hospitalists are actively engaged in the team, particularly when looking to improve the rate of malnutrition diagnosis. Hospitalists are ideally positioned to champion these efforts.”

Support for MQii was provided by Abbott, she said.
 

Reference

1. Fitall E, Bruno M, Jones K, Lynch J, Silver H, Godamunne K, Valladares A, Mitchell K. Malnutrition Care: “Low Hanging Fruit” for Hospitalist Clinical Performance Improvement [abstract]. J Hosp Med. 2017;12(suppl 2).

Hospitalists are key players in improving hospital performance, but they may be overlooking a leading cause of morbidity and mortality, especially among older adults.

Research suggests that at the time of hospital admission, some 20%-50% of all patients are at risk for malnutrition or are malnourished, but only 7% of those patients are diagnosed during their stay, according to research cited in an abstract presented at HM17.¹

“Because individuals who are malnourished lack sufficient nutrients to promote healing and rehabilitation, and are at increased risk of medical complications, it can have a serious impact on patient safety indicators, such as rates of pressure ulcers, wound healing, and risk of falls,” said lead author Eleanor Fitall of Avalere Health. “Early identification and subsequent treatment of these patients is the best way to prevent this risk.”

To address the issue, Avalere Health and the Academy of Nutrition and Dietetics established the Malnutrition Quality Improvement Initiative (MQii), a multi-stakeholder effort to identify tools to support hospital-based care teams in improving malnutrition care quality. They developed a malnutrition Toolkit, which was piloted in 2016 and was shown to effectively improve malnutrition care.

“Since the poster presentation in May, we have successfully implemented the Toolkit at 50 hospitals via a multi-hospital Learning Collaborative,” Ms. Fitall said. They are now recruiting hospitals and health systems to participate in an expanded Learning Collaborative. Interested sites should contact the MQii team at MalnutritionQuality@avalere.com.

“By supporting efforts to improve malnutrition care in the inpatient setting, hospitalists can help reduce the incidence of these problems as well as decrease rates of readmissions and reduce patient lengths of stay,” Ms. Fitall said. “Hospitalists are critical to addressing malnutrition care gaps in the hospital. Dietitians that have undertaken malnutrition quality improvement projects using the MQii Toolkit have found that they are most successful when hospitalists are actively engaged in the team, particularly when looking to improve the rate of malnutrition diagnosis. Hospitalists are ideally positioned to champion these efforts.”

Support for MQii was provided by Abbott, she said.
 

Reference

1. Fitall E, Bruno M, Jones K, Lynch J, Silver H, Godamunne K, Valladares A, Mitchell K. Malnutrition Care: “Low Hanging Fruit” for Hospitalist Clinical Performance Improvement [abstract]. J Hosp Med. 2017;12(suppl 2).

Hospitalists are key players in improving hospital performance, but they may be overlooking a leading cause of morbidity and mortality, especially among older adults.

Research suggests that at the time of hospital admission, some 20%-50% of all patients are at risk for malnutrition or are malnourished, but only 7% of those patients are diagnosed during their stay, according to research cited in an abstract presented at HM17.¹

“Because individuals who are malnourished lack sufficient nutrients to promote healing and rehabilitation, and are at increased risk of medical complications, it can have a serious impact on patient safety indicators, such as rates of pressure ulcers, wound healing, and risk of falls,” said lead author Eleanor Fitall of Avalere Health. “Early identification and subsequent treatment of these patients is the best way to prevent this risk.”

To address the issue, Avalere Health and the Academy of Nutrition and Dietetics established the Malnutrition Quality Improvement Initiative (MQii), a multi-stakeholder effort to identify tools to support hospital-based care teams in improving malnutrition care quality. They developed a malnutrition Toolkit, which was piloted in 2016 and was shown to effectively improve malnutrition care.

“Since the poster presentation in May, we have successfully implemented the Toolkit at 50 hospitals via a multi-hospital Learning Collaborative,” Ms. Fitall said. They are now recruiting hospitals and health systems to participate in an expanded Learning Collaborative. Interested sites should contact the MQii team at MalnutritionQuality@avalere.com.

“By supporting efforts to improve malnutrition care in the inpatient setting, hospitalists can help reduce the incidence of these problems as well as decrease rates of readmissions and reduce patient lengths of stay,” Ms. Fitall said. “Hospitalists are critical to addressing malnutrition care gaps in the hospital. Dietitians that have undertaken malnutrition quality improvement projects using the MQii Toolkit have found that they are most successful when hospitalists are actively engaged in the team, particularly when looking to improve the rate of malnutrition diagnosis. Hospitalists are ideally positioned to champion these efforts.”

Support for MQii was provided by Abbott, she said.
 

Reference

1. Fitall E, Bruno M, Jones K, Lynch J, Silver H, Godamunne K, Valladares A, Mitchell K. Malnutrition Care: “Low Hanging Fruit” for Hospitalist Clinical Performance Improvement [abstract]. J Hosp Med. 2017;12(suppl 2).

Hospitalists and other physicians have long struggled with medication noncompliance, which can lead to sicker patients and higher rates of readmittance, and costs some $100-$289 billion a year.

There is a growing field of digital devices being developed to address this problem. The Food and Drug Administration has just approved the newest one: a medication with a sensor embedded that can tell doctors if, and when, patients take their medicine, according to an article in the New York Times.¹ It’s expected to become available in 2018.

Reference

1. Belluck P. “First Digital Pill Approved to Worries About Biomedical ‘Big Brother.’ ” New York Times. Nov 13, 2017.

Hospitalists and other physicians have long struggled with medication noncompliance, which can lead to sicker patients and higher rates of readmittance, and costs some $100-$289 billion a year.

There is a growing field of digital devices being developed to address this problem. The Food and Drug Administration has just approved the newest one: a medication with a sensor embedded that can tell doctors if, and when, patients take their medicine, according to an article in the New York Times.¹ It’s expected to become available in 2018.

Reference

1. Belluck P. “First Digital Pill Approved to Worries About Biomedical ‘Big Brother.’ ” New York Times. Nov 13, 2017.

Hospitalists and other physicians have long struggled with medication noncompliance, which can lead to sicker patients and higher rates of readmittance, and costs some $100-$289 billion a year.

There is a growing field of digital devices being developed to address this problem. The Food and Drug Administration has just approved the newest one: a medication with a sensor embedded that can tell doctors if, and when, patients take their medicine, according to an article in the New York Times.¹ It’s expected to become available in 2018.

Reference

1. Belluck P. “First Digital Pill Approved to Worries About Biomedical ‘Big Brother.’ ” New York Times. Nov 13, 2017.

Hospitalists regularly treat patients with limited health literacy, and in many cases, the hospitalist may not even be aware of it. “Patients are unlikely to know or, more importantly, disclose their limited health literacy status,” according to a recent study.¹ But hospitalists certainly see its effects: Limited health literacy often results in poor outcomes and high rates of readmittance.

“We know patients with limited health literacy are common and that they have poor health outcomes,” said study coauthor Robert Leverence, MD. “We also know there are ways to mitigate those outcomes. For that reason, we believe screening is important. In our study, we showed such routine screening is feasible in a large teaching hospital.”

The study describes the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses and applied to all adult inpatients. “We incorporated the health literacy screen and care plan into our electronic health record,” the authors wrote. “When a patient screens positive for limited health literacy, two automated responses are triggered: a one-time alert on chart entry for all users ... and a nursing care plan containing relevant educational recommendations.”

“To me it is a cringe-worthy event to give a 10-page AVS to a patient who can’t read,” Dr. Leverence added. “Health literacy screening allows us to tailor the discharge process to meet the needs of the individual patient. Once these patients are identified, then appropriate efforts can be efficiently deployed.”

Those efforts might include, at discharge, offering easy-to-read materials and teach-back, and having a caregiver in the room and a pharmacist performing bedside medication education.
 

Reference

1. Warring C, Pinkney J, Delvo-Favre E, et al. “Implementation of a Routine Health Literacy Assessment at an Academic Medical Center.” J Healthc Qual. doi: 10.1097/JHQ.0000000000000116

Hospitalists regularly treat patients with limited health literacy, and in many cases, the hospitalist may not even be aware of it. “Patients are unlikely to know or, more importantly, disclose their limited health literacy status,” according to a recent study.¹ But hospitalists certainly see its effects: Limited health literacy often results in poor outcomes and high rates of readmittance.

“We know patients with limited health literacy are common and that they have poor health outcomes,” said study coauthor Robert Leverence, MD. “We also know there are ways to mitigate those outcomes. For that reason, we believe screening is important. In our study, we showed such routine screening is feasible in a large teaching hospital.”

The study describes the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses and applied to all adult inpatients. “We incorporated the health literacy screen and care plan into our electronic health record,” the authors wrote. “When a patient screens positive for limited health literacy, two automated responses are triggered: a one-time alert on chart entry for all users ... and a nursing care plan containing relevant educational recommendations.”

“To me it is a cringe-worthy event to give a 10-page AVS to a patient who can’t read,” Dr. Leverence added. “Health literacy screening allows us to tailor the discharge process to meet the needs of the individual patient. Once these patients are identified, then appropriate efforts can be efficiently deployed.”

Those efforts might include, at discharge, offering easy-to-read materials and teach-back, and having a caregiver in the room and a pharmacist performing bedside medication education.
 

Reference

1. Warring C, Pinkney J, Delvo-Favre E, et al. “Implementation of a Routine Health Literacy Assessment at an Academic Medical Center.” J Healthc Qual. doi: 10.1097/JHQ.0000000000000116

Hospitalists regularly treat patients with limited health literacy, and in many cases, the hospitalist may not even be aware of it. “Patients are unlikely to know or, more importantly, disclose their limited health literacy status,” according to a recent study.¹ But hospitalists certainly see its effects: Limited health literacy often results in poor outcomes and high rates of readmittance.

“We know patients with limited health literacy are common and that they have poor health outcomes,” said study coauthor Robert Leverence, MD. “We also know there are ways to mitigate those outcomes. For that reason, we believe screening is important. In our study, we showed such routine screening is feasible in a large teaching hospital.”

The study describes the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses and applied to all adult inpatients. “We incorporated the health literacy screen and care plan into our electronic health record,” the authors wrote. “When a patient screens positive for limited health literacy, two automated responses are triggered: a one-time alert on chart entry for all users ... and a nursing care plan containing relevant educational recommendations.”

“To me it is a cringe-worthy event to give a 10-page AVS to a patient who can’t read,” Dr. Leverence added. “Health literacy screening allows us to tailor the discharge process to meet the needs of the individual patient. Once these patients are identified, then appropriate efforts can be efficiently deployed.”

Those efforts might include, at discharge, offering easy-to-read materials and teach-back, and having a caregiver in the room and a pharmacist performing bedside medication education.
 

Reference

1. Warring C, Pinkney J, Delvo-Favre E, et al. “Implementation of a Routine Health Literacy Assessment at an Academic Medical Center.” J Healthc Qual. doi: 10.1097/JHQ.0000000000000116

Hospitalists see patients at their most fragile – and, as a result, they have a unique opportunity to affect their health going forward.

“These moments can transform the way patients see their health and their behaviors, and any opportunity to position patients as empowered to influence their experience is one that can not be squandered,” said Timothy Huerta, PhD, MS, lead author on a study of patient portals and tablets during inpatient care.¹ “In that context, hospitals have the opportunity to set expectations for engagement that can be influenced by technology. Patient portals, positioned within the inpatient setting, offer a platform to engage, empower, and educate.”

His experience – at the first and largest academic medical center to provide this technology across the entire hospital system – offers the first insight into the demands that such a process shift requires, he said. The researchers ran a 90-day pilot program giving tablets to 179 patients; subsequently, the health system committed to providing tablets for accessing inpatient portals in all seven of its hospitals. “Adopting this technology is not easy, and we continue to explore how we can use it more effectively. Our hope is that our experience can make the journey of others easier.”

Reference

1. Huerta T, McAlearney AS, Rizer MK. “Introducing a Patient Portal and Electronic Tablets to Inpatient Care.” Ann Intern Med. 2017;167(11):816-7.

Hospitalists see patients at their most fragile – and, as a result, they have a unique opportunity to affect their health going forward.

“These moments can transform the way patients see their health and their behaviors, and any opportunity to position patients as empowered to influence their experience is one that can not be squandered,” said Timothy Huerta, PhD, MS, lead author on a study of patient portals and tablets during inpatient care.¹ “In that context, hospitals have the opportunity to set expectations for engagement that can be influenced by technology. Patient portals, positioned within the inpatient setting, offer a platform to engage, empower, and educate.”

His experience – at the first and largest academic medical center to provide this technology across the entire hospital system – offers the first insight into the demands that such a process shift requires, he said. The researchers ran a 90-day pilot program giving tablets to 179 patients; subsequently, the health system committed to providing tablets for accessing inpatient portals in all seven of its hospitals. “Adopting this technology is not easy, and we continue to explore how we can use it more effectively. Our hope is that our experience can make the journey of others easier.”

Reference

1. Huerta T, McAlearney AS, Rizer MK. “Introducing a Patient Portal and Electronic Tablets to Inpatient Care.” Ann Intern Med. 2017;167(11):816-7.

Hospitalists see patients at their most fragile – and, as a result, they have a unique opportunity to affect their health going forward.

“These moments can transform the way patients see their health and their behaviors, and any opportunity to position patients as empowered to influence their experience is one that can not be squandered,” said Timothy Huerta, PhD, MS, lead author on a study of patient portals and tablets during inpatient care.¹ “In that context, hospitals have the opportunity to set expectations for engagement that can be influenced by technology. Patient portals, positioned within the inpatient setting, offer a platform to engage, empower, and educate.”

His experience – at the first and largest academic medical center to provide this technology across the entire hospital system – offers the first insight into the demands that such a process shift requires, he said. The researchers ran a 90-day pilot program giving tablets to 179 patients; subsequently, the health system committed to providing tablets for accessing inpatient portals in all seven of its hospitals. “Adopting this technology is not easy, and we continue to explore how we can use it more effectively. Our hope is that our experience can make the journey of others easier.”

Reference

1. Huerta T, McAlearney AS, Rizer MK. “Introducing a Patient Portal and Electronic Tablets to Inpatient Care.” Ann Intern Med. 2017;167(11):816-7.

Background: Literature regarding patient satisfaction often focuses on nonspecific recommendations to improve patient-centered communication. There is lack of guidance on concrete advice for clinicians, particularly with regard to how a provider’s responses to different patient requests are received.

Study design: Cross-sectional study.

Setting: An outpatient family medicine clinic.

Synopsis: Patient requests from 1,141 patients visiting the University of California, Davis, Family Medicine Clinic were sampled. The study examined clinician’s approval or denial of patients’ requests for referrals, pain medications, other new medicines, laboratory testing, radiology testing, or other testing and the patients’ reported satisfaction of the clinician.

Clinician denial of particular requests was associated with decreased patient satisfaction. Specifically, a 19.75% drop for referral, 10.72% drop for pain medication, 20.36% drop for other new medications, and 9.19% drop for laboratory test. This study did not examine other potential reasons for decreased satisfaction.

Bottom line: Clinicians can better understand how to communicate in a patient-centered manner by understanding that not all patient requests are perceived as equal.

Citation: Jerant A et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

Dr. Shaffie is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Literature regarding patient satisfaction often focuses on nonspecific recommendations to improve patient-centered communication. There is lack of guidance on concrete advice for clinicians, particularly with regard to how a provider’s responses to different patient requests are received.

Study design: Cross-sectional study.

Setting: An outpatient family medicine clinic.

Synopsis: Patient requests from 1,141 patients visiting the University of California, Davis, Family Medicine Clinic were sampled. The study examined clinician’s approval or denial of patients’ requests for referrals, pain medications, other new medicines, laboratory testing, radiology testing, or other testing and the patients’ reported satisfaction of the clinician.

Clinician denial of particular requests was associated with decreased patient satisfaction. Specifically, a 19.75% drop for referral, 10.72% drop for pain medication, 20.36% drop for other new medications, and 9.19% drop for laboratory test. This study did not examine other potential reasons for decreased satisfaction.

Bottom line: Clinicians can better understand how to communicate in a patient-centered manner by understanding that not all patient requests are perceived as equal.

Citation: Jerant A et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

Dr. Shaffie is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Literature regarding patient satisfaction often focuses on nonspecific recommendations to improve patient-centered communication. There is lack of guidance on concrete advice for clinicians, particularly with regard to how a provider’s responses to different patient requests are received.

Study design: Cross-sectional study.

Setting: An outpatient family medicine clinic.

Synopsis: Patient requests from 1,141 patients visiting the University of California, Davis, Family Medicine Clinic were sampled. The study examined clinician’s approval or denial of patients’ requests for referrals, pain medications, other new medicines, laboratory testing, radiology testing, or other testing and the patients’ reported satisfaction of the clinician.

Clinician denial of particular requests was associated with decreased patient satisfaction. Specifically, a 19.75% drop for referral, 10.72% drop for pain medication, 20.36% drop for other new medications, and 9.19% drop for laboratory test. This study did not examine other potential reasons for decreased satisfaction.

Bottom line: Clinicians can better understand how to communicate in a patient-centered manner by understanding that not all patient requests are perceived as equal.

Citation: Jerant A et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

Dr. Shaffie is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.



In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.

Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.

Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.



In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.

Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.

Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.



In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.

Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.

Clinical question: Are patient perceptions of care during index hospitalization associated with likelihood of 30-day readmission?

Background: Hospital readmissions are costly (more than $40 billion annually) and common. Nearly one readmission in five is thought to be preventable. While many risk-prediction models exist, few incorporate patient perceptions during the index hospitalization or factors associated with patient experience.

Clinical question: Are patient perceptions of care during index hospitalization associated with likelihood of 30-day readmission?

Background: Hospital readmissions are costly (more than $40 billion annually) and common. Nearly one readmission in five is thought to be preventable. While many risk-prediction models exist, few incorporate patient perceptions during the index hospitalization or factors associated with patient experience.

Clinical question: Are patient perceptions of care during index hospitalization associated with likelihood of 30-day readmission?

Background: Hospital readmissions are costly (more than $40 billion annually) and common. Nearly one readmission in five is thought to be preventable. While many risk-prediction models exist, few incorporate patient perceptions during the index hospitalization or factors associated with patient experience.

Clinical question: Are there differences in mortality and health care resource utilization in patients treated by hospitalists, primary care physicians, or other generalists?

Background: Most hospitalized patients now are being cared for by hospitalists rather than their primary care physicians (PCP). Covering generalists, who lack a prior relationship with the patient, also care for hospitalized patients when their PCP is unavailable. Although past studies have found some differences in outcomes in patients when care was provided by hospitalists vs. PCPs, those studies have grouped covering generalists with PCPs, which could affect the data.

Clinical question: Are there differences in mortality and health care resource utilization in patients treated by hospitalists, primary care physicians, or other generalists?

Background: Most hospitalized patients now are being cared for by hospitalists rather than their primary care physicians (PCP). Covering generalists, who lack a prior relationship with the patient, also care for hospitalized patients when their PCP is unavailable. Although past studies have found some differences in outcomes in patients when care was provided by hospitalists vs. PCPs, those studies have grouped covering generalists with PCPs, which could affect the data.

Clinical question: Are there differences in mortality and health care resource utilization in patients treated by hospitalists, primary care physicians, or other generalists?

Background: Most hospitalized patients now are being cared for by hospitalists rather than their primary care physicians (PCP). Covering generalists, who lack a prior relationship with the patient, also care for hospitalized patients when their PCP is unavailable. Although past studies have found some differences in outcomes in patients when care was provided by hospitalists vs. PCPs, those studies have grouped covering generalists with PCPs, which could affect the data.

Hospital Medicine: 10 years ago

My first Society of Hospital Medicine Annual Conference was HM08, and it changed the course of my professional career.

I was a first-year hospitalist from an academic program of fewer than 10 physicians. My knowledge about my field did not extend much beyond the clinical practice of hospital medicine. I remember sitting at the airport on my way to HM08 and excitedly looking over the schedule for the meeting. I diligently circled the sessions that I was looking forward to attending, the majority of which focused on the clinical tracks. But by the end of the meeting, in additional to valuable medical knowledge, I walked away with novel insights that launched me into my future.

New ideas in HM: In 2008, comanagement was still a new concept. As I attended sessions and spoke with hospitalists from across the country, it became clear that this was a collaboration that would be core to our specialty. Within a couple of months of returning home from the annual conference, I was approached by the chair of neurosurgery at my institution with a proposal to develop a quality program for his group. While at that time I was considering other competing interests, my experience at HM08 helped me recognize that this was a unique opportunity to build bridges across specialties and to collaborate. I subsequently became the executive director of quality for neurosurgery and over the years was able to create a strong relationship between our departments that led to building a nationally recognized program with exceptional performance in hospital-based quality.

Side note: If you’re interested in resources on comanagement, please check out SHM’s Resources for Effective Co-Management of Hospitalized Patients at https://www.hospitalmedicine.org/comanagement .

Emerging themes and trends in health care: While the quality movement had launched about a decade before HM08, many institutions still did not have robust programs. As I attended sessions during the annual meeting and spoke with thought leaders, one message became clear: Hospitalists would have to lead the quality movement at their institutions. When I returned home, I began learning about quality improvement and started to lead various initiatives. These efforts led to my appointment as associate chief medical officer for the health system. This position enabled me to leverage my knowledge of hospital-based care and collaborate across various specialties to reduce our mortality and readmission rates in the organization.

Side note: If you’re interested in learning more about quality improvement educational and mentorship opportunities, please visit https://www.hospitalmedicine.org/qi and look at the resources for each specific topic.

And, most importantly, friendships: By far the most important thing I took away from HM08 was the friendships that started at that meeting and have developed over the years since. A decade later, I continue to rely on, grow from, and be challenged by the same people I met at that meeting. They are the colleagues I call when I find myself in a tough spot at work and need advice, the collaborators I work with on grants and projects, and the friends I text when I travel to a new town and want to grab a bite to eat.

Side note: If you’re interested in connecting with colleagues who share similar interests, please visit https://www.hospitalmedicine.org/sigs and review SHM’s Special Interest Groups to find ones that are right for you. To connect on a more local level, find an SHM Chapter near you at https://www.hospitalmedicine.org/chapters.

I’ve shared these stories with you because for me my journey with our society has been a deeply personal one. And I feel indebted to SHM and the incredible people who drawn to it for helping me develop and enjoy a rich and rewarding career thus far. So, as I look forward to the next decade, I wanted to share my thoughts on HM and emerging themes in health care with you.
 

Hospital medicine: The next decade

New ideas in HM: Population health management

Building on our strong culture of collaboration as we move forward into this next decade, we have to define how we deliver value in the context of population health management. As hospitalists, we have to push the boundaries of the hospital and provide high-value care beyond our four walls.

How can we do that? I think technology will play a critical role in extending our reach beyond the hospital. As we move toward delivering greater value to our patients, lower acuity patients will receive care in their homes. Telehealth will enable us to monitor and manage these patients remotely while transferring our bedside management to patients’ bedrooms in their own homes. Virtual hospitals will further enable us to evaluate, triage, monitor, and manage patients remotely. Our active engagement in these efforts is critical to ensure the continued growth and value we bring to our patients, our organizations, and our society.
 

Emerging themes and trends in health care: Transitioning from quality to value

In the next decade, value will prevail. This is not a novel concept – much like how quality was not a new idea in 2008.

Value has been around for a while: There are some robust programs nationally, there is research around the topic, and there are policies with implications for reimbursements. However, the full potential of value has not yet been realized by health care – it exists in individual programs, not in everything we do. The unprecedented number of mergers and acquisitions in health care in 2018 support the fact that the future will belong to those institutions that can deliver the highest quality of care at the most appropriate cost throughout the entire continuum of care.

What are some of the tools that will help us get there? Artificial intelligence and machine learning will improve the predictive value for the care we deliver to individual patients; some preliminary work in this area has already revealed that factors that we previously associated with higher risk of readmissions are not truly predictive. Another emerging technology is blockchain: By creating a single source of truth for our patients’ medical information, it enables us to have dynamic, high-integrity records regardless of which health systems and EHRs have cared for those patients.

I wish you an energizing journey as you launch your future into the next dynamic decade of health care, and I look forward to connecting with you as we continue to build a society that prepares us for the challenges and opportunities ahead.
 

Dr. Afsar is the president of the Society of Hospital Medicine and the chief ambulatory officer and chief medical officer for the accountable care organizations at UC Irvine Health.

Hospital Medicine: 10 years ago

My first Society of Hospital Medicine Annual Conference was HM08, and it changed the course of my professional career.

I was a first-year hospitalist from an academic program of fewer than 10 physicians. My knowledge about my field did not extend much beyond the clinical practice of hospital medicine. I remember sitting at the airport on my way to HM08 and excitedly looking over the schedule for the meeting. I diligently circled the sessions that I was looking forward to attending, the majority of which focused on the clinical tracks. But by the end of the meeting, in additional to valuable medical knowledge, I walked away with novel insights that launched me into my future.

New ideas in HM: In 2008, comanagement was still a new concept. As I attended sessions and spoke with hospitalists from across the country, it became clear that this was a collaboration that would be core to our specialty. Within a couple of months of returning home from the annual conference, I was approached by the chair of neurosurgery at my institution with a proposal to develop a quality program for his group. While at that time I was considering other competing interests, my experience at HM08 helped me recognize that this was a unique opportunity to build bridges across specialties and to collaborate. I subsequently became the executive director of quality for neurosurgery and over the years was able to create a strong relationship between our departments that led to building a nationally recognized program with exceptional performance in hospital-based quality.

Side note: If you’re interested in resources on comanagement, please check out SHM’s Resources for Effective Co-Management of Hospitalized Patients at https://www.hospitalmedicine.org/comanagement .

Emerging themes and trends in health care: While the quality movement had launched about a decade before HM08, many institutions still did not have robust programs. As I attended sessions during the annual meeting and spoke with thought leaders, one message became clear: Hospitalists would have to lead the quality movement at their institutions. When I returned home, I began learning about quality improvement and started to lead various initiatives. These efforts led to my appointment as associate chief medical officer for the health system. This position enabled me to leverage my knowledge of hospital-based care and collaborate across various specialties to reduce our mortality and readmission rates in the organization.

Side note: If you’re interested in learning more about quality improvement educational and mentorship opportunities, please visit https://www.hospitalmedicine.org/qi and look at the resources for each specific topic.

And, most importantly, friendships: By far the most important thing I took away from HM08 was the friendships that started at that meeting and have developed over the years since. A decade later, I continue to rely on, grow from, and be challenged by the same people I met at that meeting. They are the colleagues I call when I find myself in a tough spot at work and need advice, the collaborators I work with on grants and projects, and the friends I text when I travel to a new town and want to grab a bite to eat.

Side note: If you’re interested in connecting with colleagues who share similar interests, please visit https://www.hospitalmedicine.org/sigs and review SHM’s Special Interest Groups to find ones that are right for you. To connect on a more local level, find an SHM Chapter near you at https://www.hospitalmedicine.org/chapters.

I’ve shared these stories with you because for me my journey with our society has been a deeply personal one. And I feel indebted to SHM and the incredible people who drawn to it for helping me develop and enjoy a rich and rewarding career thus far. So, as I look forward to the next decade, I wanted to share my thoughts on HM and emerging themes in health care with you.
 

Hospital medicine: The next decade

New ideas in HM: Population health management

Building on our strong culture of collaboration as we move forward into this next decade, we have to define how we deliver value in the context of population health management. As hospitalists, we have to push the boundaries of the hospital and provide high-value care beyond our four walls.

How can we do that? I think technology will play a critical role in extending our reach beyond the hospital. As we move toward delivering greater value to our patients, lower acuity patients will receive care in their homes. Telehealth will enable us to monitor and manage these patients remotely while transferring our bedside management to patients’ bedrooms in their own homes. Virtual hospitals will further enable us to evaluate, triage, monitor, and manage patients remotely. Our active engagement in these efforts is critical to ensure the continued growth and value we bring to our patients, our organizations, and our society.
 

Emerging themes and trends in health care: Transitioning from quality to value

In the next decade, value will prevail. This is not a novel concept – much like how quality was not a new idea in 2008.

Value has been around for a while: There are some robust programs nationally, there is research around the topic, and there are policies with implications for reimbursements. However, the full potential of value has not yet been realized by health care – it exists in individual programs, not in everything we do. The unprecedented number of mergers and acquisitions in health care in 2018 support the fact that the future will belong to those institutions that can deliver the highest quality of care at the most appropriate cost throughout the entire continuum of care.

What are some of the tools that will help us get there? Artificial intelligence and machine learning will improve the predictive value for the care we deliver to individual patients; some preliminary work in this area has already revealed that factors that we previously associated with higher risk of readmissions are not truly predictive. Another emerging technology is blockchain: By creating a single source of truth for our patients’ medical information, it enables us to have dynamic, high-integrity records regardless of which health systems and EHRs have cared for those patients.

I wish you an energizing journey as you launch your future into the next dynamic decade of health care, and I look forward to connecting with you as we continue to build a society that prepares us for the challenges and opportunities ahead.
 

Dr. Afsar is the president of the Society of Hospital Medicine and the chief ambulatory officer and chief medical officer for the accountable care organizations at UC Irvine Health.

Hospital Medicine: 10 years ago

My first Society of Hospital Medicine Annual Conference was HM08, and it changed the course of my professional career.

I was a first-year hospitalist from an academic program of fewer than 10 physicians. My knowledge about my field did not extend much beyond the clinical practice of hospital medicine. I remember sitting at the airport on my way to HM08 and excitedly looking over the schedule for the meeting. I diligently circled the sessions that I was looking forward to attending, the majority of which focused on the clinical tracks. But by the end of the meeting, in additional to valuable medical knowledge, I walked away with novel insights that launched me into my future.

New ideas in HM: In 2008, comanagement was still a new concept. As I attended sessions and spoke with hospitalists from across the country, it became clear that this was a collaboration that would be core to our specialty. Within a couple of months of returning home from the annual conference, I was approached by the chair of neurosurgery at my institution with a proposal to develop a quality program for his group. While at that time I was considering other competing interests, my experience at HM08 helped me recognize that this was a unique opportunity to build bridges across specialties and to collaborate. I subsequently became the executive director of quality for neurosurgery and over the years was able to create a strong relationship between our departments that led to building a nationally recognized program with exceptional performance in hospital-based quality.

Side note: If you’re interested in resources on comanagement, please check out SHM’s Resources for Effective Co-Management of Hospitalized Patients at https://www.hospitalmedicine.org/comanagement .

Emerging themes and trends in health care: While the quality movement had launched about a decade before HM08, many institutions still did not have robust programs. As I attended sessions during the annual meeting and spoke with thought leaders, one message became clear: Hospitalists would have to lead the quality movement at their institutions. When I returned home, I began learning about quality improvement and started to lead various initiatives. These efforts led to my appointment as associate chief medical officer for the health system. This position enabled me to leverage my knowledge of hospital-based care and collaborate across various specialties to reduce our mortality and readmission rates in the organization.

Side note: If you’re interested in learning more about quality improvement educational and mentorship opportunities, please visit https://www.hospitalmedicine.org/qi and look at the resources for each specific topic.

And, most importantly, friendships: By far the most important thing I took away from HM08 was the friendships that started at that meeting and have developed over the years since. A decade later, I continue to rely on, grow from, and be challenged by the same people I met at that meeting. They are the colleagues I call when I find myself in a tough spot at work and need advice, the collaborators I work with on grants and projects, and the friends I text when I travel to a new town and want to grab a bite to eat.

Side note: If you’re interested in connecting with colleagues who share similar interests, please visit https://www.hospitalmedicine.org/sigs and review SHM’s Special Interest Groups to find ones that are right for you. To connect on a more local level, find an SHM Chapter near you at https://www.hospitalmedicine.org/chapters.

I’ve shared these stories with you because for me my journey with our society has been a deeply personal one. And I feel indebted to SHM and the incredible people who drawn to it for helping me develop and enjoy a rich and rewarding career thus far. So, as I look forward to the next decade, I wanted to share my thoughts on HM and emerging themes in health care with you.
 

Hospital medicine: The next decade

New ideas in HM: Population health management

Building on our strong culture of collaboration as we move forward into this next decade, we have to define how we deliver value in the context of population health management. As hospitalists, we have to push the boundaries of the hospital and provide high-value care beyond our four walls.

How can we do that? I think technology will play a critical role in extending our reach beyond the hospital. As we move toward delivering greater value to our patients, lower acuity patients will receive care in their homes. Telehealth will enable us to monitor and manage these patients remotely while transferring our bedside management to patients’ bedrooms in their own homes. Virtual hospitals will further enable us to evaluate, triage, monitor, and manage patients remotely. Our active engagement in these efforts is critical to ensure the continued growth and value we bring to our patients, our organizations, and our society.
 

Emerging themes and trends in health care: Transitioning from quality to value

In the next decade, value will prevail. This is not a novel concept – much like how quality was not a new idea in 2008.

Value has been around for a while: There are some robust programs nationally, there is research around the topic, and there are policies with implications for reimbursements. However, the full potential of value has not yet been realized by health care – it exists in individual programs, not in everything we do. The unprecedented number of mergers and acquisitions in health care in 2018 support the fact that the future will belong to those institutions that can deliver the highest quality of care at the most appropriate cost throughout the entire continuum of care.

What are some of the tools that will help us get there? Artificial intelligence and machine learning will improve the predictive value for the care we deliver to individual patients; some preliminary work in this area has already revealed that factors that we previously associated with higher risk of readmissions are not truly predictive. Another emerging technology is blockchain: By creating a single source of truth for our patients’ medical information, it enables us to have dynamic, high-integrity records regardless of which health systems and EHRs have cared for those patients.

I wish you an energizing journey as you launch your future into the next dynamic decade of health care, and I look forward to connecting with you as we continue to build a society that prepares us for the challenges and opportunities ahead.
 

Dr. Afsar is the president of the Society of Hospital Medicine and the chief ambulatory officer and chief medical officer for the accountable care organizations at UC Irvine Health.