Quality

Hospitalist Prabhbir Singh, MD, was the chief hospitalist with Sound Physicians at 62-bed Sutter Amador Hospital in Jackson, Calif., several years ago when in came a 55-year-old man with a serious problem: gangrenous cholecystitis, inflammation of the gallbladder in which the gallbladder tissue is starting to die.

 

Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.

 

“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”

 

Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.

 

The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.

 

Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.

 

The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.

 

“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.

 

A Clear Delineation

Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.

 

When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.

 

One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.

 

“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”

 

 

Remaining Challenges

The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.

 

John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.

 

Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.

 

“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”

 

The details depend on the hospital, she says.

 

“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”

 

To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.

 

At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.

 

Reported outcomes, however, seem to be mixed.

 

In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2

 

The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.

 

But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.

 

“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”

 

 

Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”

 

 

---

 

Thomas R. Collins is a freelance medical writer based in Florida.

 

References

 

 

 

 

1. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
2. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

 

Hospitalist Prabhbir Singh, MD, was the chief hospitalist with Sound Physicians at 62-bed Sutter Amador Hospital in Jackson, Calif., several years ago when in came a 55-year-old man with a serious problem: gangrenous cholecystitis, inflammation of the gallbladder in which the gallbladder tissue is starting to die.

 

Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.

 

“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”

 

Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.

 

The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.

 

Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.

 

The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.

 

“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.

 

A Clear Delineation

Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.

 

When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.

 

One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.

 

“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”

 

 

Remaining Challenges

The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.

 

John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.

 

Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.

 

“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”

 

The details depend on the hospital, she says.

 

“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”

 

To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.

 

At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.

 

Reported outcomes, however, seem to be mixed.

 

In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2

 

The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.

 

But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.

 

“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”

 

 

Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”

 

 

---

 

Thomas R. Collins is a freelance medical writer based in Florida.

 

References

 

 

 

 

1. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
2. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

 

Hospitalist Prabhbir Singh, MD, was the chief hospitalist with Sound Physicians at 62-bed Sutter Amador Hospital in Jackson, Calif., several years ago when in came a 55-year-old man with a serious problem: gangrenous cholecystitis, inflammation of the gallbladder in which the gallbladder tissue is starting to die.

 

Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.

 

“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”

 

Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.

 

The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.

 

Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.

 

The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.

 

“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.

 

A Clear Delineation

Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.

 

When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.

 

One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.

 

“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”

 

 

Remaining Challenges

The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.

 

John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.

 

Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.

 

“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”

 

The details depend on the hospital, she says.

 

“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”

 

To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.

 

At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.

 

Reported outcomes, however, seem to be mixed.

 

In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2

 

The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.

 

But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.

 

“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”

 

 

Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”

 

 

---

 

Thomas R. Collins is a freelance medical writer based in Florida.

 

References

 

 

 

 

1. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
2. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

 

From celebrating the 20th anniversary of hospital medicine’s arrival to rapid reimbursement reform to sought-after clarity for observation rules, the past 12 months have been eventful. The Hospitalist asked more than a dozen industry leaders what they thought were the biggest highlights of 2016. Here is what they said:

1. Happy Birthday, HM

August 15 marked the 20th anniversary of “The Emerging Role of ‘Hospitalists’ in the American Health Care System,”1 a New England Journal of Medicine paper authored by Lee Goldman, MD, and Robert Wachter, MD, MHM.2 It was the first time anyone defined what a hospitalist was, putting a sobriquet to an inpatient care model that had organically and independently started happening nationwide.

The paper laid the groundwork for a specialty that spread like a proverbial wildfire over the next 20 years. The model overcame early opposition from residents fearful they’d lose the ability to learn and critical-care specialists who wanted to maintain the caseloads they’d fought to build. The field has now swelled to an estimated 52,000 practitioners.

“I reflect back … and think today about what the hospitalist model brings to us,” James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division, told The Hospitalist. “It is an amazing transformation on how the hospitalist model really delivers.”1

2. Its Own Specialty Code

Hospitalist medicine received federal approval for its first dedicated specialty code3 in a decision hailed by many. The code, approved by the Centers for Medicare & Medicaid Services (CMS), should allow hospitalist-specific billing in 2017.

SHM leaders have long pushed for the code, particularly as healthcare transitions from fee-for-service (FFS) to quality-based payment models. Public Policy Committee Chair Ron Greeno, MD, MHM, says that a dedicated code is necessary to ensure that hospitalists are properly reimbursed for their work.

Historically, hospitalists have used codes more in line with the workload of general internal medicine, family medicine, and other specialties. But those codes don’t account for the complexity of what hospitalists deal with on a daily basis.

“We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties,” Dr. Greeno said.3

SHM pushed for the change and has said it is committed to educating members about how best to use it. Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians of Tacoma, Wash., said the move is great for HM but that more needs to be done to tailor billing and coding to the specialty’s actual workflow.

“A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears said. “I don’t think it’s an end-all, be-all, but it’s a place to start.”3

3. Down with SGR, Long Live MACRA

While it’s unlikely hospitalists have that printed on bumper stickers, 2016 brought the end of the oft-maligned Sustainable Growth Rate (SGR) formula. This was the first year under the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.4

MACRA changes the ways hospitalists and other physicians are reimbursed by Medicare by continuing the broader trend of moving from volume-based reimbursements toward a value-based payment (VBP) system. Its two tracks for physicians to change how they get paid are the Merit-Based Incentive Payment System (MIPS) and the Alternative Payments Model (APM).

MIPS probably looks familiar because it is similar to the traditional FFS model. But to make value a more important factor in the reimbursement formula, MIPS will account for both volume and quality. APM allows physicians to opt out of MIPS by participating in other approved programs where providers take on “more than nominal” financial risk, report on their quality measures, and use certified electronic health record (EHR) technology.

 

4. The Surgeon General Is a Hospitalist

Any specialty’s annual meeting would be lucky to get the U.S. Surgeon General as a plenary speaker, but HM16 featured one of its own in hospitalist and U.S. Surgeon General Vivek Murthy, MD, MBA.

Dr. Murthy kicked off the confab in San Diego, and some 4,000 hospitalists listened to one of their own talk about ascending the highest perch a physician can attain in the federal government.7 Dr. Murthy, previously a hospitalist at Brigham and Women’s Hospital in Boston, was confirmed as the 19th Surgeon General in December 2014.

In an address titled “Bringing Health to America,” Dr. Murthy inspired with tales of hope and encouraged hospitalists to make the pursuit of healthy appealing while improving the safety of our communities. In particular, he suggested hospitalists look to leverage their leadership to improve systems and to be a powerful force of change both inside the walls of their institution and in their communities.

“In the end, the world gets better when people choose to come together to make it better,” he said.8

5. Nurse Practitioner Joins SHM Board of Directors

At HM16, Tracy Cardin, ACNP-BC, SFHM, was the first nurse practitioner (NP) or physician assistant (PA) given voting privileges on the society’s oversight panel.

“I can’t describe to you how passionately I believe that [NPs and PAs] have a huge role moving forward,” Cardin said. “I think our representation, our visibility, has sort of been flabby and kind of under the wire for a long time. We can really impact the design of care models at the bedside in a way that’s innovative and more efficient and in a way that’s really huge. I think there’s a transformation that’s going to be coming, and we’re going to be a huge part of it.”9

With Cardin’s ascension, it has added the voice of another constituency to its board. She was previously chair of SHM’s Nurse Practitioner/Physician Assistant Committee and in 2015 received the society’s Award in Excellence in Hospital Medicine for NPs and PAs. She has been at the University of Chicago for about 10 years.

“It does send a message to the rest of our membership that SHM values those other constituencies and that this is not a physician membership organization but rather a membership organization comprised of people who are interested in improving healthcare for our hospitalized patients,” immediate past president Robert Harrington Jr., MD, SFHM said.10

6. The State of Hospital Medicine Is Strong

According to the biennial 2016 State of Hospital Medicine Report6 from SHM and partially populated by data from the Medical Group Management Association (MGMA), median compensation for adult hospitalists rose 10% to $278,746 from 2013 to 2015. The double-digit increase continues the steady climb of hospitalist pay, which is up 30% since 2010. At the same time, productivity is flattening.

And nearly all HM groups (HMGs)—96%—are still getting financial support, mostly from their host hospitals, in addition to their professional fee revenue. However, that median support, $157,535 per full-time employee (FTE), increased just 1%.

The slowing growth in that contribution is a harbinger that the level of financial support can no longer grow unabated, said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

“We’re pretty close to that breaking point,” she said. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”6

 

7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More

CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.

The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.

For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”

But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.

8. Medicaid Expansion Takes Hold

Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14

“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15

While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.

9. Antimicrobial Stewardship Rules Upgrade

In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.

“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16

The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.

Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.

 

10. Febrile-Infant Care Draws a Crowd

One of the most well-attended sessions at 2016 Pediatric Hospital Medicine in Chicago was an update on the anticipated American Academy of Pediatricians (AAP) guidelines for febrile infants.18

The guidelines, for infants 7–90 days old, are aimed at providing pediatric hospitalists and others evidence-based guidelines, not rules, from the most recent literature available. The PHM16 session, presented by Kenneth Roberts, MD, highlighted the need to separate individual components of serious bacterial infections such as urinary tract infections (UTIs), bacteremia, and meningitis. Dr. Roberts noted that the incidence and clinical course can vary greatly for the different diagnoses.

The new criteria would be for full-term infants (37–43 weeks’ gestation) who are well-appearing and present with a temperature of 38°C. Exclusion criteria would include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

In particular, the new guidelines will look to risk-stratify management by age groups of 7–28 days, 29–60 days, and 61–90 days. The criteria are expected to be released in the next year.

---

Richard Quinn is a freelance writer in New Jersey.

References

1. Quinn R. HM turns 20: a look at the evolution of hospitalist medicine. The Hospitalist website. Accessed November 14, 2016.
2. Wachter M, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
3. Tyrrell KA. New hospitalist billing code should benefit hospitalists, patients. The Hospitalist website. Accessed November 14, 2016.
4. Doctoroff L, Dutta S. MACRA provides new direction for U.S. healthcare. The Hospitalist website. Accessed November 14, 2016.
5. Quinn R. Everything you need to know about the Bundled Payments for Care Improvement Initiative. The Hospitalist website. Accessed November 14, 2016.
6. Quinn R. The state of hospital medicine is strong. The Hospitalist website. Accessed November 14, 2016.
7. Scheurer D. U.S. surgeon general encourages hospitalists to remain hopeful, motivated. The Hospitalist website. Accessed November 14, 2016.
8. Collins TR. HM16 speakers focus on public health, leadership, future of hospital medicine. The Hospitalist website. Accessed November 14, 2016.
9. Quinn R. SHM seats its first non-physician board member. The Hospitalist website. Accessed at November 14, 2016.
10. Carris J. Centers for Medicare & Medicaid Services (CMS) eliminates two-midnight rule’s inpatient payment cuts: report. The Hospitalist website. Accessed November 14, 2016.
11. Schencker L. Judge tells HHS to revisit two-midnight rule’s inpatient pay cut. Healh Affairs website. Accessed November 14, 2016.
12. Tyrrell KA. Physicians critical of proposed changes to Medicare’s two-midnight rule. The Hospitalist website. Accessed November 14, 2016.
13. Tyrrell KA. Ann Sheehy, MD, MS, FHM, outlines to lawmakers hospitalist concerns about two-midnight rule, Medicare policies. The Hospitalist website. Accessed November 14, 2016.
14. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff (Millwood). 2016;35(1):106-110.
15. Tyrrell KA. Benefits of Medicaid expansion for hospitalists. The Hospitalist website. Accessed November 14, 2016.
16. Bopp S. New standard announced for antimicrobial stewardship. The Hospitalist website. Accessed November 14, 2016.
17. Prepublication standards – new antimicrobial stewardship standard. The Joint Commission website. Accessed November 14, 2016.
18. 18. DeZure C. PHM16: the new AAP clinical practice guideline on evaluating, managing febrile infants. The Hospitalist website. Accessed November 14, 2016.

From celebrating the 20th anniversary of hospital medicine’s arrival to rapid reimbursement reform to sought-after clarity for observation rules, the past 12 months have been eventful. The Hospitalist asked more than a dozen industry leaders what they thought were the biggest highlights of 2016. Here is what they said:

1. Happy Birthday, HM

August 15 marked the 20th anniversary of “The Emerging Role of ‘Hospitalists’ in the American Health Care System,”1 a New England Journal of Medicine paper authored by Lee Goldman, MD, and Robert Wachter, MD, MHM.2 It was the first time anyone defined what a hospitalist was, putting a sobriquet to an inpatient care model that had organically and independently started happening nationwide.

The paper laid the groundwork for a specialty that spread like a proverbial wildfire over the next 20 years. The model overcame early opposition from residents fearful they’d lose the ability to learn and critical-care specialists who wanted to maintain the caseloads they’d fought to build. The field has now swelled to an estimated 52,000 practitioners.

“I reflect back … and think today about what the hospitalist model brings to us,” James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division, told The Hospitalist. “It is an amazing transformation on how the hospitalist model really delivers.”1

2. Its Own Specialty Code

Hospitalist medicine received federal approval for its first dedicated specialty code3 in a decision hailed by many. The code, approved by the Centers for Medicare & Medicaid Services (CMS), should allow hospitalist-specific billing in 2017.

SHM leaders have long pushed for the code, particularly as healthcare transitions from fee-for-service (FFS) to quality-based payment models. Public Policy Committee Chair Ron Greeno, MD, MHM, says that a dedicated code is necessary to ensure that hospitalists are properly reimbursed for their work.

Historically, hospitalists have used codes more in line with the workload of general internal medicine, family medicine, and other specialties. But those codes don’t account for the complexity of what hospitalists deal with on a daily basis.

“We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties,” Dr. Greeno said.3

SHM pushed for the change and has said it is committed to educating members about how best to use it. Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians of Tacoma, Wash., said the move is great for HM but that more needs to be done to tailor billing and coding to the specialty’s actual workflow.

“A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears said. “I don’t think it’s an end-all, be-all, but it’s a place to start.”3

3. Down with SGR, Long Live MACRA

While it’s unlikely hospitalists have that printed on bumper stickers, 2016 brought the end of the oft-maligned Sustainable Growth Rate (SGR) formula. This was the first year under the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.4

MACRA changes the ways hospitalists and other physicians are reimbursed by Medicare by continuing the broader trend of moving from volume-based reimbursements toward a value-based payment (VBP) system. Its two tracks for physicians to change how they get paid are the Merit-Based Incentive Payment System (MIPS) and the Alternative Payments Model (APM).

MIPS probably looks familiar because it is similar to the traditional FFS model. But to make value a more important factor in the reimbursement formula, MIPS will account for both volume and quality. APM allows physicians to opt out of MIPS by participating in other approved programs where providers take on “more than nominal” financial risk, report on their quality measures, and use certified electronic health record (EHR) technology.

 

4. The Surgeon General Is a Hospitalist

Any specialty’s annual meeting would be lucky to get the U.S. Surgeon General as a plenary speaker, but HM16 featured one of its own in hospitalist and U.S. Surgeon General Vivek Murthy, MD, MBA.

Dr. Murthy kicked off the confab in San Diego, and some 4,000 hospitalists listened to one of their own talk about ascending the highest perch a physician can attain in the federal government.7 Dr. Murthy, previously a hospitalist at Brigham and Women’s Hospital in Boston, was confirmed as the 19th Surgeon General in December 2014.

In an address titled “Bringing Health to America,” Dr. Murthy inspired with tales of hope and encouraged hospitalists to make the pursuit of healthy appealing while improving the safety of our communities. In particular, he suggested hospitalists look to leverage their leadership to improve systems and to be a powerful force of change both inside the walls of their institution and in their communities.

“In the end, the world gets better when people choose to come together to make it better,” he said.8

5. Nurse Practitioner Joins SHM Board of Directors

At HM16, Tracy Cardin, ACNP-BC, SFHM, was the first nurse practitioner (NP) or physician assistant (PA) given voting privileges on the society’s oversight panel.

“I can’t describe to you how passionately I believe that [NPs and PAs] have a huge role moving forward,” Cardin said. “I think our representation, our visibility, has sort of been flabby and kind of under the wire for a long time. We can really impact the design of care models at the bedside in a way that’s innovative and more efficient and in a way that’s really huge. I think there’s a transformation that’s going to be coming, and we’re going to be a huge part of it.”9

With Cardin’s ascension, it has added the voice of another constituency to its board. She was previously chair of SHM’s Nurse Practitioner/Physician Assistant Committee and in 2015 received the society’s Award in Excellence in Hospital Medicine for NPs and PAs. She has been at the University of Chicago for about 10 years.

“It does send a message to the rest of our membership that SHM values those other constituencies and that this is not a physician membership organization but rather a membership organization comprised of people who are interested in improving healthcare for our hospitalized patients,” immediate past president Robert Harrington Jr., MD, SFHM said.10

6. The State of Hospital Medicine Is Strong

According to the biennial 2016 State of Hospital Medicine Report6 from SHM and partially populated by data from the Medical Group Management Association (MGMA), median compensation for adult hospitalists rose 10% to $278,746 from 2013 to 2015. The double-digit increase continues the steady climb of hospitalist pay, which is up 30% since 2010. At the same time, productivity is flattening.

And nearly all HM groups (HMGs)—96%—are still getting financial support, mostly from their host hospitals, in addition to their professional fee revenue. However, that median support, $157,535 per full-time employee (FTE), increased just 1%.

The slowing growth in that contribution is a harbinger that the level of financial support can no longer grow unabated, said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

“We’re pretty close to that breaking point,” she said. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”6

 

7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More

CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.

The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.

For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”

But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.

8. Medicaid Expansion Takes Hold

Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14

“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15

While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.

9. Antimicrobial Stewardship Rules Upgrade

In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.

“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16

The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.

Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.

 

10. Febrile-Infant Care Draws a Crowd

One of the most well-attended sessions at 2016 Pediatric Hospital Medicine in Chicago was an update on the anticipated American Academy of Pediatricians (AAP) guidelines for febrile infants.18

The guidelines, for infants 7–90 days old, are aimed at providing pediatric hospitalists and others evidence-based guidelines, not rules, from the most recent literature available. The PHM16 session, presented by Kenneth Roberts, MD, highlighted the need to separate individual components of serious bacterial infections such as urinary tract infections (UTIs), bacteremia, and meningitis. Dr. Roberts noted that the incidence and clinical course can vary greatly for the different diagnoses.

The new criteria would be for full-term infants (37–43 weeks’ gestation) who are well-appearing and present with a temperature of 38°C. Exclusion criteria would include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

In particular, the new guidelines will look to risk-stratify management by age groups of 7–28 days, 29–60 days, and 61–90 days. The criteria are expected to be released in the next year.

---

Richard Quinn is a freelance writer in New Jersey.

References

1. Quinn R. HM turns 20: a look at the evolution of hospitalist medicine. The Hospitalist website. Accessed November 14, 2016.
2. Wachter M, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
3. Tyrrell KA. New hospitalist billing code should benefit hospitalists, patients. The Hospitalist website. Accessed November 14, 2016.
4. Doctoroff L, Dutta S. MACRA provides new direction for U.S. healthcare. The Hospitalist website. Accessed November 14, 2016.
5. Quinn R. Everything you need to know about the Bundled Payments for Care Improvement Initiative. The Hospitalist website. Accessed November 14, 2016.
6. Quinn R. The state of hospital medicine is strong. The Hospitalist website. Accessed November 14, 2016.
7. Scheurer D. U.S. surgeon general encourages hospitalists to remain hopeful, motivated. The Hospitalist website. Accessed November 14, 2016.
8. Collins TR. HM16 speakers focus on public health, leadership, future of hospital medicine. The Hospitalist website. Accessed November 14, 2016.
9. Quinn R. SHM seats its first non-physician board member. The Hospitalist website. Accessed at November 14, 2016.
10. Carris J. Centers for Medicare & Medicaid Services (CMS) eliminates two-midnight rule’s inpatient payment cuts: report. The Hospitalist website. Accessed November 14, 2016.
11. Schencker L. Judge tells HHS to revisit two-midnight rule’s inpatient pay cut. Healh Affairs website. Accessed November 14, 2016.
12. Tyrrell KA. Physicians critical of proposed changes to Medicare’s two-midnight rule. The Hospitalist website. Accessed November 14, 2016.
13. Tyrrell KA. Ann Sheehy, MD, MS, FHM, outlines to lawmakers hospitalist concerns about two-midnight rule, Medicare policies. The Hospitalist website. Accessed November 14, 2016.
14. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff (Millwood). 2016;35(1):106-110.
15. Tyrrell KA. Benefits of Medicaid expansion for hospitalists. The Hospitalist website. Accessed November 14, 2016.
16. Bopp S. New standard announced for antimicrobial stewardship. The Hospitalist website. Accessed November 14, 2016.
17. Prepublication standards – new antimicrobial stewardship standard. The Joint Commission website. Accessed November 14, 2016.
18. 18. DeZure C. PHM16: the new AAP clinical practice guideline on evaluating, managing febrile infants. The Hospitalist website. Accessed November 14, 2016.

From celebrating the 20th anniversary of hospital medicine’s arrival to rapid reimbursement reform to sought-after clarity for observation rules, the past 12 months have been eventful. The Hospitalist asked more than a dozen industry leaders what they thought were the biggest highlights of 2016. Here is what they said:

1. Happy Birthday, HM

August 15 marked the 20th anniversary of “The Emerging Role of ‘Hospitalists’ in the American Health Care System,”1 a New England Journal of Medicine paper authored by Lee Goldman, MD, and Robert Wachter, MD, MHM.2 It was the first time anyone defined what a hospitalist was, putting a sobriquet to an inpatient care model that had organically and independently started happening nationwide.

The paper laid the groundwork for a specialty that spread like a proverbial wildfire over the next 20 years. The model overcame early opposition from residents fearful they’d lose the ability to learn and critical-care specialists who wanted to maintain the caseloads they’d fought to build. The field has now swelled to an estimated 52,000 practitioners.

“I reflect back … and think today about what the hospitalist model brings to us,” James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division, told The Hospitalist. “It is an amazing transformation on how the hospitalist model really delivers.”1

2. Its Own Specialty Code

Hospitalist medicine received federal approval for its first dedicated specialty code3 in a decision hailed by many. The code, approved by the Centers for Medicare & Medicaid Services (CMS), should allow hospitalist-specific billing in 2017.

SHM leaders have long pushed for the code, particularly as healthcare transitions from fee-for-service (FFS) to quality-based payment models. Public Policy Committee Chair Ron Greeno, MD, MHM, says that a dedicated code is necessary to ensure that hospitalists are properly reimbursed for their work.

Historically, hospitalists have used codes more in line with the workload of general internal medicine, family medicine, and other specialties. But those codes don’t account for the complexity of what hospitalists deal with on a daily basis.

“We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties,” Dr. Greeno said.3

SHM pushed for the change and has said it is committed to educating members about how best to use it. Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians of Tacoma, Wash., said the move is great for HM but that more needs to be done to tailor billing and coding to the specialty’s actual workflow.

“A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears said. “I don’t think it’s an end-all, be-all, but it’s a place to start.”3

3. Down with SGR, Long Live MACRA

While it’s unlikely hospitalists have that printed on bumper stickers, 2016 brought the end of the oft-maligned Sustainable Growth Rate (SGR) formula. This was the first year under the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.4

MACRA changes the ways hospitalists and other physicians are reimbursed by Medicare by continuing the broader trend of moving from volume-based reimbursements toward a value-based payment (VBP) system. Its two tracks for physicians to change how they get paid are the Merit-Based Incentive Payment System (MIPS) and the Alternative Payments Model (APM).

MIPS probably looks familiar because it is similar to the traditional FFS model. But to make value a more important factor in the reimbursement formula, MIPS will account for both volume and quality. APM allows physicians to opt out of MIPS by participating in other approved programs where providers take on “more than nominal” financial risk, report on their quality measures, and use certified electronic health record (EHR) technology.

 

4. The Surgeon General Is a Hospitalist

Any specialty’s annual meeting would be lucky to get the U.S. Surgeon General as a plenary speaker, but HM16 featured one of its own in hospitalist and U.S. Surgeon General Vivek Murthy, MD, MBA.

Dr. Murthy kicked off the confab in San Diego, and some 4,000 hospitalists listened to one of their own talk about ascending the highest perch a physician can attain in the federal government.7 Dr. Murthy, previously a hospitalist at Brigham and Women’s Hospital in Boston, was confirmed as the 19th Surgeon General in December 2014.

In an address titled “Bringing Health to America,” Dr. Murthy inspired with tales of hope and encouraged hospitalists to make the pursuit of healthy appealing while improving the safety of our communities. In particular, he suggested hospitalists look to leverage their leadership to improve systems and to be a powerful force of change both inside the walls of their institution and in their communities.

“In the end, the world gets better when people choose to come together to make it better,” he said.8

5. Nurse Practitioner Joins SHM Board of Directors

At HM16, Tracy Cardin, ACNP-BC, SFHM, was the first nurse practitioner (NP) or physician assistant (PA) given voting privileges on the society’s oversight panel.

“I can’t describe to you how passionately I believe that [NPs and PAs] have a huge role moving forward,” Cardin said. “I think our representation, our visibility, has sort of been flabby and kind of under the wire for a long time. We can really impact the design of care models at the bedside in a way that’s innovative and more efficient and in a way that’s really huge. I think there’s a transformation that’s going to be coming, and we’re going to be a huge part of it.”9

With Cardin’s ascension, it has added the voice of another constituency to its board. She was previously chair of SHM’s Nurse Practitioner/Physician Assistant Committee and in 2015 received the society’s Award in Excellence in Hospital Medicine for NPs and PAs. She has been at the University of Chicago for about 10 years.

“It does send a message to the rest of our membership that SHM values those other constituencies and that this is not a physician membership organization but rather a membership organization comprised of people who are interested in improving healthcare for our hospitalized patients,” immediate past president Robert Harrington Jr., MD, SFHM said.10

6. The State of Hospital Medicine Is Strong

According to the biennial 2016 State of Hospital Medicine Report6 from SHM and partially populated by data from the Medical Group Management Association (MGMA), median compensation for adult hospitalists rose 10% to $278,746 from 2013 to 2015. The double-digit increase continues the steady climb of hospitalist pay, which is up 30% since 2010. At the same time, productivity is flattening.

And nearly all HM groups (HMGs)—96%—are still getting financial support, mostly from their host hospitals, in addition to their professional fee revenue. However, that median support, $157,535 per full-time employee (FTE), increased just 1%.

The slowing growth in that contribution is a harbinger that the level of financial support can no longer grow unabated, said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

“We’re pretty close to that breaking point,” she said. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”6

 

7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More

CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.

The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.

For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”

But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.

8. Medicaid Expansion Takes Hold

Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14

“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15

While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.

9. Antimicrobial Stewardship Rules Upgrade

In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.

“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16

The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.

Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.

 

10. Febrile-Infant Care Draws a Crowd

One of the most well-attended sessions at 2016 Pediatric Hospital Medicine in Chicago was an update on the anticipated American Academy of Pediatricians (AAP) guidelines for febrile infants.18

The guidelines, for infants 7–90 days old, are aimed at providing pediatric hospitalists and others evidence-based guidelines, not rules, from the most recent literature available. The PHM16 session, presented by Kenneth Roberts, MD, highlighted the need to separate individual components of serious bacterial infections such as urinary tract infections (UTIs), bacteremia, and meningitis. Dr. Roberts noted that the incidence and clinical course can vary greatly for the different diagnoses.

The new criteria would be for full-term infants (37–43 weeks’ gestation) who are well-appearing and present with a temperature of 38°C. Exclusion criteria would include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

In particular, the new guidelines will look to risk-stratify management by age groups of 7–28 days, 29–60 days, and 61–90 days. The criteria are expected to be released in the next year.

---

Richard Quinn is a freelance writer in New Jersey.

References

1. Quinn R. HM turns 20: a look at the evolution of hospitalist medicine. The Hospitalist website. Accessed November 14, 2016.
2. Wachter M, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
3. Tyrrell KA. New hospitalist billing code should benefit hospitalists, patients. The Hospitalist website. Accessed November 14, 2016.
4. Doctoroff L, Dutta S. MACRA provides new direction for U.S. healthcare. The Hospitalist website. Accessed November 14, 2016.
5. Quinn R. Everything you need to know about the Bundled Payments for Care Improvement Initiative. The Hospitalist website. Accessed November 14, 2016.
6. Quinn R. The state of hospital medicine is strong. The Hospitalist website. Accessed November 14, 2016.
7. Scheurer D. U.S. surgeon general encourages hospitalists to remain hopeful, motivated. The Hospitalist website. Accessed November 14, 2016.
8. Collins TR. HM16 speakers focus on public health, leadership, future of hospital medicine. The Hospitalist website. Accessed November 14, 2016.
9. Quinn R. SHM seats its first non-physician board member. The Hospitalist website. Accessed at November 14, 2016.
10. Carris J. Centers for Medicare & Medicaid Services (CMS) eliminates two-midnight rule’s inpatient payment cuts: report. The Hospitalist website. Accessed November 14, 2016.
11. Schencker L. Judge tells HHS to revisit two-midnight rule’s inpatient pay cut. Healh Affairs website. Accessed November 14, 2016.
12. Tyrrell KA. Physicians critical of proposed changes to Medicare’s two-midnight rule. The Hospitalist website. Accessed November 14, 2016.
13. Tyrrell KA. Ann Sheehy, MD, MS, FHM, outlines to lawmakers hospitalist concerns about two-midnight rule, Medicare policies. The Hospitalist website. Accessed November 14, 2016.
14. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff (Millwood). 2016;35(1):106-110.
15. Tyrrell KA. Benefits of Medicaid expansion for hospitalists. The Hospitalist website. Accessed November 14, 2016.
16. Bopp S. New standard announced for antimicrobial stewardship. The Hospitalist website. Accessed November 14, 2016.
17. Prepublication standards – new antimicrobial stewardship standard. The Joint Commission website. Accessed November 14, 2016.
18. 18. DeZure C. PHM16: the new AAP clinical practice guideline on evaluating, managing febrile infants. The Hospitalist website. Accessed November 14, 2016.

 

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

“Previous studies across surgical fields have shown significant associations between patient characteristics including age, sex, comorbidity status, race, and insurance level, and outcomes following a range of surgical procedures,” Ms. Brownlee, a medical student at Loyola University Chicago’s Stritch School of Medicine, said at the annual meeting of the Western Surgical Association. “Identifying these associations has helped guide clinical practice and decision-making for both surgeons and patients, and has called attention to areas of health disparities in surgical care. More recently, other aspects of the CDM, including hospital factors like staffing ratios, procedure volume, and the availability of rehabilitation and specialized nursing services, have been investigated to assess the influence these components might have on patient outcomes postoperatively. However, it’s not known how much hospital factors such as these contribute to the variation in surgical outcomes overall. It’s important to know what changes we can make that will have the biggest impact on improving patient outcomes, so that efforts on reducing readmissions are appropriately designed.”

The purpose of the current study was to determine the relative contribution of various aspects of the CDM to 1-year readmission risk after surgery. Working with colleagues Anai Kothari, MD, and Paul Kuo MD, in the One:MAP Section of Clinical informatics and Analytics in the department of surgery at Loyola University Medical Center, Ms. Brownlee analyzed the Healthcare Cost and Utilization Project State Inpatient Databases from Florida, New York, and Washington between 2009 and 2013, which were linked to the American Hospital Association Annual Survey from that same time period.

The researchers used smoothed hazard estimates to determine all-cause readmission in the year after surgery, and multilevel survival models with shared frailty to determine the relative impact of hospital versus patient characteristics on the heterogeneity of readmission risk between hospitals. They limited the analysis to patients aged 18 years and older who underwent one the following procedures: abdominal aortic aneurysm repair, pancreatectomy, colectomy, coronary artery bypass graft, and total hip arthroplasty.

Ms. Brownlee reported results from 502,157 patients who underwent surgical procedures at 347 hospitals. The 1-year readmission rate was 23.5%, and ranged from 12% to 36% across procedures. After controlling for procedure, the researchers observed a 7.9% variation in readmission risk between hospitals. Staffing accounted for 9.8% of variance, followed by hospital structural characteristics such as teaching status and clinical programs (7.5%), patient ZIP code (3.8%), hospital perioperative resources such as inpatient rehab (2.9%), hospital volume (2.8%), and patient clinical characteristics (2.1%). The following hospital characteristics were significantly associated with a lower risk of 1-year readmission: high physician/bed ratio (hazard ratio 0.85; P = .00017); transplant status (HR 0.87; P = .022); high-income ZIP code (HR 0.89; P less than .001); high nurse bed/bed ratio (HR 0.90; P = .047), and cancer center designation (HR 0.93; P = .021).

“Compared to patient clinical characteristics, hospital factors such as staffing ratios, perioperative resources, and structural elements account for more variation in postoperative outcomes,” Ms. Brownlee concluded. “However, it’s important to note that in the present study, over 70% of variation in readmission rates is not explained by the covariates that we analyzed. It’s possible that there are other factors we need to consider. That’s where the direction of this research is going. Much of the variation in readmission risk across hospitals cannot be characterized with currently utilized administrative data.”

The National Institutes of Health provided funding for the study. Ms. Brownlee reported having no financial disclosures.

dbrunk@frontlinemedcom.com

 

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

“Previous studies across surgical fields have shown significant associations between patient characteristics including age, sex, comorbidity status, race, and insurance level, and outcomes following a range of surgical procedures,” Ms. Brownlee, a medical student at Loyola University Chicago’s Stritch School of Medicine, said at the annual meeting of the Western Surgical Association. “Identifying these associations has helped guide clinical practice and decision-making for both surgeons and patients, and has called attention to areas of health disparities in surgical care. More recently, other aspects of the CDM, including hospital factors like staffing ratios, procedure volume, and the availability of rehabilitation and specialized nursing services, have been investigated to assess the influence these components might have on patient outcomes postoperatively. However, it’s not known how much hospital factors such as these contribute to the variation in surgical outcomes overall. It’s important to know what changes we can make that will have the biggest impact on improving patient outcomes, so that efforts on reducing readmissions are appropriately designed.”

The purpose of the current study was to determine the relative contribution of various aspects of the CDM to 1-year readmission risk after surgery. Working with colleagues Anai Kothari, MD, and Paul Kuo MD, in the One:MAP Section of Clinical informatics and Analytics in the department of surgery at Loyola University Medical Center, Ms. Brownlee analyzed the Healthcare Cost and Utilization Project State Inpatient Databases from Florida, New York, and Washington between 2009 and 2013, which were linked to the American Hospital Association Annual Survey from that same time period.

The researchers used smoothed hazard estimates to determine all-cause readmission in the year after surgery, and multilevel survival models with shared frailty to determine the relative impact of hospital versus patient characteristics on the heterogeneity of readmission risk between hospitals. They limited the analysis to patients aged 18 years and older who underwent one the following procedures: abdominal aortic aneurysm repair, pancreatectomy, colectomy, coronary artery bypass graft, and total hip arthroplasty.

Ms. Brownlee reported results from 502,157 patients who underwent surgical procedures at 347 hospitals. The 1-year readmission rate was 23.5%, and ranged from 12% to 36% across procedures. After controlling for procedure, the researchers observed a 7.9% variation in readmission risk between hospitals. Staffing accounted for 9.8% of variance, followed by hospital structural characteristics such as teaching status and clinical programs (7.5%), patient ZIP code (3.8%), hospital perioperative resources such as inpatient rehab (2.9%), hospital volume (2.8%), and patient clinical characteristics (2.1%). The following hospital characteristics were significantly associated with a lower risk of 1-year readmission: high physician/bed ratio (hazard ratio 0.85; P = .00017); transplant status (HR 0.87; P = .022); high-income ZIP code (HR 0.89; P less than .001); high nurse bed/bed ratio (HR 0.90; P = .047), and cancer center designation (HR 0.93; P = .021).

“Compared to patient clinical characteristics, hospital factors such as staffing ratios, perioperative resources, and structural elements account for more variation in postoperative outcomes,” Ms. Brownlee concluded. “However, it’s important to note that in the present study, over 70% of variation in readmission rates is not explained by the covariates that we analyzed. It’s possible that there are other factors we need to consider. That’s where the direction of this research is going. Much of the variation in readmission risk across hospitals cannot be characterized with currently utilized administrative data.”

The National Institutes of Health provided funding for the study. Ms. Brownlee reported having no financial disclosures.

dbrunk@frontlinemedcom.com

 

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

“Previous studies across surgical fields have shown significant associations between patient characteristics including age, sex, comorbidity status, race, and insurance level, and outcomes following a range of surgical procedures,” Ms. Brownlee, a medical student at Loyola University Chicago’s Stritch School of Medicine, said at the annual meeting of the Western Surgical Association. “Identifying these associations has helped guide clinical practice and decision-making for both surgeons and patients, and has called attention to areas of health disparities in surgical care. More recently, other aspects of the CDM, including hospital factors like staffing ratios, procedure volume, and the availability of rehabilitation and specialized nursing services, have been investigated to assess the influence these components might have on patient outcomes postoperatively. However, it’s not known how much hospital factors such as these contribute to the variation in surgical outcomes overall. It’s important to know what changes we can make that will have the biggest impact on improving patient outcomes, so that efforts on reducing readmissions are appropriately designed.”

The purpose of the current study was to determine the relative contribution of various aspects of the CDM to 1-year readmission risk after surgery. Working with colleagues Anai Kothari, MD, and Paul Kuo MD, in the One:MAP Section of Clinical informatics and Analytics in the department of surgery at Loyola University Medical Center, Ms. Brownlee analyzed the Healthcare Cost and Utilization Project State Inpatient Databases from Florida, New York, and Washington between 2009 and 2013, which were linked to the American Hospital Association Annual Survey from that same time period.

The researchers used smoothed hazard estimates to determine all-cause readmission in the year after surgery, and multilevel survival models with shared frailty to determine the relative impact of hospital versus patient characteristics on the heterogeneity of readmission risk between hospitals. They limited the analysis to patients aged 18 years and older who underwent one the following procedures: abdominal aortic aneurysm repair, pancreatectomy, colectomy, coronary artery bypass graft, and total hip arthroplasty.

Ms. Brownlee reported results from 502,157 patients who underwent surgical procedures at 347 hospitals. The 1-year readmission rate was 23.5%, and ranged from 12% to 36% across procedures. After controlling for procedure, the researchers observed a 7.9% variation in readmission risk between hospitals. Staffing accounted for 9.8% of variance, followed by hospital structural characteristics such as teaching status and clinical programs (7.5%), patient ZIP code (3.8%), hospital perioperative resources such as inpatient rehab (2.9%), hospital volume (2.8%), and patient clinical characteristics (2.1%). The following hospital characteristics were significantly associated with a lower risk of 1-year readmission: high physician/bed ratio (hazard ratio 0.85; P = .00017); transplant status (HR 0.87; P = .022); high-income ZIP code (HR 0.89; P less than .001); high nurse bed/bed ratio (HR 0.90; P = .047), and cancer center designation (HR 0.93; P = .021).

“Compared to patient clinical characteristics, hospital factors such as staffing ratios, perioperative resources, and structural elements account for more variation in postoperative outcomes,” Ms. Brownlee concluded. “However, it’s important to note that in the present study, over 70% of variation in readmission rates is not explained by the covariates that we analyzed. It’s possible that there are other factors we need to consider. That’s where the direction of this research is going. Much of the variation in readmission risk across hospitals cannot be characterized with currently utilized administrative data.”

The National Institutes of Health provided funding for the study. Ms. Brownlee reported having no financial disclosures.

dbrunk@frontlinemedcom.com

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

 

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

---

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

 

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

---

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

 

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

---

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

 

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

 

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

 

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

---

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

 

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

 

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

 

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

 

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

---

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

 

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

 

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

 

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

 

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

---

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

 

Rates of 30-day readmissions, which are both common and difficult to predict, are of major concern to hospitalists.

“Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types,” according to a recent article in the Journal of Hospital Medicine. “One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions.”

This fact led the authors to perform a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) could predict 30-day hospital readmission. The 36 variables in the CDA algorithm included age, radiologic agents, and temperature. The retrospective study assessed 3,015 patients admitted to eight general medicine units for all-cause 30-day readmission. Of these, 1,141 patients triggered a CDA, and they were significantly more likely to have a 30-day readmission compared to those who did not trigger a CDA (23.6% versus 15.9%).

The researchers concluded that readily identifiable clinical variables can be identified that predict 30-day readmission.

“It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be ‘fair’ to institutions that care for more seriously ill patients,” they write. “The development of an accurate real-time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death and post-discharge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations.”

Reference

1. Micek ST, Samant M, Bailey T, et al. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission [published online ahead of print June 3, 2016]. J Hosp Med. doi:10.1002/jhm.2617.

 

Quick Byte

The Cost of Vaccine Avoidance

Many Americans avoid their recommended vaccines: For example, the Centers for Disease Control and Prevention (CDC) reports that only 42% of U.S. adults age 18 or older received the flu vaccine during the 2015–2016 flu season. A study recently released online by Health Affairs calculated the annual cost of the diseases associated with 10 vaccines the CDC recommends for adults. In 2015, that economic burden was $8.95 billion. A full 80% of that—$7.1 billion—was attributed to unvaccinated people.

Reference

1. The cost of US adult vaccine avoidance: $8.95 billion in 2015. Health Affairs website. Accessed October 17, 2016

Rates of 30-day readmissions, which are both common and difficult to predict, are of major concern to hospitalists.

“Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types,” according to a recent article in the Journal of Hospital Medicine. “One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions.”

This fact led the authors to perform a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) could predict 30-day hospital readmission. The 36 variables in the CDA algorithm included age, radiologic agents, and temperature. The retrospective study assessed 3,015 patients admitted to eight general medicine units for all-cause 30-day readmission. Of these, 1,141 patients triggered a CDA, and they were significantly more likely to have a 30-day readmission compared to those who did not trigger a CDA (23.6% versus 15.9%).

The researchers concluded that readily identifiable clinical variables can be identified that predict 30-day readmission.

“It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be ‘fair’ to institutions that care for more seriously ill patients,” they write. “The development of an accurate real-time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death and post-discharge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations.”

Reference

1. Micek ST, Samant M, Bailey T, et al. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission [published online ahead of print June 3, 2016]. J Hosp Med. doi:10.1002/jhm.2617.

 

Quick Byte

The Cost of Vaccine Avoidance

Many Americans avoid their recommended vaccines: For example, the Centers for Disease Control and Prevention (CDC) reports that only 42% of U.S. adults age 18 or older received the flu vaccine during the 2015–2016 flu season. A study recently released online by Health Affairs calculated the annual cost of the diseases associated with 10 vaccines the CDC recommends for adults. In 2015, that economic burden was $8.95 billion. A full 80% of that—$7.1 billion—was attributed to unvaccinated people.

Reference

1. The cost of US adult vaccine avoidance: $8.95 billion in 2015. Health Affairs website. Accessed October 17, 2016

Rates of 30-day readmissions, which are both common and difficult to predict, are of major concern to hospitalists.

“Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types,” according to a recent article in the Journal of Hospital Medicine. “One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions.”

This fact led the authors to perform a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) could predict 30-day hospital readmission. The 36 variables in the CDA algorithm included age, radiologic agents, and temperature. The retrospective study assessed 3,015 patients admitted to eight general medicine units for all-cause 30-day readmission. Of these, 1,141 patients triggered a CDA, and they were significantly more likely to have a 30-day readmission compared to those who did not trigger a CDA (23.6% versus 15.9%).

The researchers concluded that readily identifiable clinical variables can be identified that predict 30-day readmission.

“It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be ‘fair’ to institutions that care for more seriously ill patients,” they write. “The development of an accurate real-time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death and post-discharge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations.”

Reference

1. Micek ST, Samant M, Bailey T, et al. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission [published online ahead of print June 3, 2016]. J Hosp Med. doi:10.1002/jhm.2617.

 

Quick Byte

The Cost of Vaccine Avoidance

Many Americans avoid their recommended vaccines: For example, the Centers for Disease Control and Prevention (CDC) reports that only 42% of U.S. adults age 18 or older received the flu vaccine during the 2015–2016 flu season. A study recently released online by Health Affairs calculated the annual cost of the diseases associated with 10 vaccines the CDC recommends for adults. In 2015, that economic burden was $8.95 billion. A full 80% of that—$7.1 billion—was attributed to unvaccinated people.

Reference

1. The cost of US adult vaccine avoidance: $8.95 billion in 2015. Health Affairs website. Accessed October 17, 2016

Twenty percent of Americans live in areas where there are shortages of physicians, according to a policy brief in Health Affairs. Some analysts believe the answer to this problem is telehealth, which they say could also save the healthcare industry some $4.28 billion annually.

While the Affordable Care Act signaled a move toward telehealth development at the federal level (through Medicare), states still largely govern coverage of telehealth services by Medicaid or private insurers.

“Currently there is no uniform legal approach to telehealth, and this continues to be a major challenge in its provision. In particular, concerns about reimbursements, for both private insurers and public programs such as Medicaid, continue to limit the implementation and use of telehealth services,” according to the brief.

Now, Congress is considering the Medicare Telehealth Parity Act, intended to modernize the way Medicare reimburses telehealth services and to expand locations and coverage. To enjoy the benefits of telehealth services, states are likely to move toward full-parity laws for the services, the brief notes.

“Without parity, there are limited incentives for the development of telehealth or for providers to move toward telehealth services,” according to the brief. “If there are no incentives to use telehealth, then providers will continue to focus on in-person care, which will keep healthcare costs high, continue to create access issues, and possibly provide lesser standards of care for chronic disease patients who benefit from remote monitoring.”

Reference

1. Yang T. Telehealth parity laws. Health Affairs Website. Accessed October 17, 2016.

Twenty percent of Americans live in areas where there are shortages of physicians, according to a policy brief in Health Affairs. Some analysts believe the answer to this problem is telehealth, which they say could also save the healthcare industry some $4.28 billion annually.

While the Affordable Care Act signaled a move toward telehealth development at the federal level (through Medicare), states still largely govern coverage of telehealth services by Medicaid or private insurers.

“Currently there is no uniform legal approach to telehealth, and this continues to be a major challenge in its provision. In particular, concerns about reimbursements, for both private insurers and public programs such as Medicaid, continue to limit the implementation and use of telehealth services,” according to the brief.

Now, Congress is considering the Medicare Telehealth Parity Act, intended to modernize the way Medicare reimburses telehealth services and to expand locations and coverage. To enjoy the benefits of telehealth services, states are likely to move toward full-parity laws for the services, the brief notes.

“Without parity, there are limited incentives for the development of telehealth or for providers to move toward telehealth services,” according to the brief. “If there are no incentives to use telehealth, then providers will continue to focus on in-person care, which will keep healthcare costs high, continue to create access issues, and possibly provide lesser standards of care for chronic disease patients who benefit from remote monitoring.”

Reference

1. Yang T. Telehealth parity laws. Health Affairs Website. Accessed October 17, 2016.

Twenty percent of Americans live in areas where there are shortages of physicians, according to a policy brief in Health Affairs. Some analysts believe the answer to this problem is telehealth, which they say could also save the healthcare industry some $4.28 billion annually.

While the Affordable Care Act signaled a move toward telehealth development at the federal level (through Medicare), states still largely govern coverage of telehealth services by Medicaid or private insurers.

“Currently there is no uniform legal approach to telehealth, and this continues to be a major challenge in its provision. In particular, concerns about reimbursements, for both private insurers and public programs such as Medicaid, continue to limit the implementation and use of telehealth services,” according to the brief.

Now, Congress is considering the Medicare Telehealth Parity Act, intended to modernize the way Medicare reimburses telehealth services and to expand locations and coverage. To enjoy the benefits of telehealth services, states are likely to move toward full-parity laws for the services, the brief notes.

“Without parity, there are limited incentives for the development of telehealth or for providers to move toward telehealth services,” according to the brief. “If there are no incentives to use telehealth, then providers will continue to focus on in-person care, which will keep healthcare costs high, continue to create access issues, and possibly provide lesser standards of care for chronic disease patients who benefit from remote monitoring.”

Reference

1. Yang T. Telehealth parity laws. Health Affairs Website. Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

Take a quick glance through the medical literature, and chances are good that you’ll find a study citing low or variable adherence to clinical guidelines.

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

 

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

 

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

 

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

---

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

 

Take a quick glance through the medical literature, and chances are good that you’ll find a study citing low or variable adherence to clinical guidelines.

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

 

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

 

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

 

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

---

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

 

Take a quick glance through the medical literature, and chances are good that you’ll find a study citing low or variable adherence to clinical guidelines.

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

 

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

 

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

 

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

---

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.