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Reducing adverse drug reactions
Easing the inpatient/outpatient transition
Adverse drug reactions are a problem hospitalists encounter often. An estimated 9% of hospital admissions in older adults are the result of adverse drug reactions, and up to one in five adults experience an adverse drug reaction during hospitalization.
“Many interventions have been tried to solve this problem, and certain of them have worked, but to date we don’t have any great solutions that meaningfully impact the rate of these events in a way that’s feasible in most health care environments, so any efforts to reduce the burden of these problems in older adults could be hugely beneficial,” said Michael Steinman, MD, author of an editorial highlighting a new approach.
His editorial in BMJ Quality & Safety cites research on the Pharm2Pharm program, implemented in six Hawaiian hospitals, in which hospital-based pharmacists identified inpatients at high risk of medication misadventures with criteria such as use of multiple medications, presence of high-risk medications such as warfarin or glucose-lowering drugs, and a history of previous acute care use resulting from medication-related problems. The hospital pharmacist would then meet with the patient to reconcile medications and facilitate a coordinated hand-off to a community pharmacist, who would meet with the patient after discharge.
In addition to a 36% reduction in the rate of medication-related hospitalizations, the intervention generated an estimated savings of $6.6 million per year in avoided hospitalizations.
There are two major takeaways, said Dr. Steinman, who is based in the division of geriatrics at the University of California, San Francisco: It’s critical to focus on transitions and coordination between inpatient and outpatient care to address medication-related problems, and pharmacists can be extremely helpful in that.
“Decisions about drug therapy in the hospital may seem reasonable in the short term but often won’t stick in the long term unless there is a coordinated care that can help ensure appropriate follow-through once patients return home,” Dr. Steinman said. “The study that the editorial references is a systems intervention that hospitalists can advocate for in their own institutions, but in the immediate day-to-day, trying to ensure solid coordination of medication management from the inpatient to outpatient setting is likely to be very helpful for their patients.”
The long-term outcomes of hospitalized patients are largely influenced by getting them set up with appropriate community resources and supports once they leave the hospital, he added, and the hospital can play a critical role in putting these pieces into place.
Reference
1. Steinman MA. Reducing hospital admissions for adverse drug events through coordinated pharmacist care: learning from Hawai’i without a field trip. BMJ Qual Saf. Epub 2018 Nov 24. doi: 10.1136/bmjqs-2018-008815. Accessed Dec. 11, 2018.
Easing the inpatient/outpatient transition
Easing the inpatient/outpatient transition
Adverse drug reactions are a problem hospitalists encounter often. An estimated 9% of hospital admissions in older adults are the result of adverse drug reactions, and up to one in five adults experience an adverse drug reaction during hospitalization.
“Many interventions have been tried to solve this problem, and certain of them have worked, but to date we don’t have any great solutions that meaningfully impact the rate of these events in a way that’s feasible in most health care environments, so any efforts to reduce the burden of these problems in older adults could be hugely beneficial,” said Michael Steinman, MD, author of an editorial highlighting a new approach.
His editorial in BMJ Quality & Safety cites research on the Pharm2Pharm program, implemented in six Hawaiian hospitals, in which hospital-based pharmacists identified inpatients at high risk of medication misadventures with criteria such as use of multiple medications, presence of high-risk medications such as warfarin or glucose-lowering drugs, and a history of previous acute care use resulting from medication-related problems. The hospital pharmacist would then meet with the patient to reconcile medications and facilitate a coordinated hand-off to a community pharmacist, who would meet with the patient after discharge.
In addition to a 36% reduction in the rate of medication-related hospitalizations, the intervention generated an estimated savings of $6.6 million per year in avoided hospitalizations.
There are two major takeaways, said Dr. Steinman, who is based in the division of geriatrics at the University of California, San Francisco: It’s critical to focus on transitions and coordination between inpatient and outpatient care to address medication-related problems, and pharmacists can be extremely helpful in that.
“Decisions about drug therapy in the hospital may seem reasonable in the short term but often won’t stick in the long term unless there is a coordinated care that can help ensure appropriate follow-through once patients return home,” Dr. Steinman said. “The study that the editorial references is a systems intervention that hospitalists can advocate for in their own institutions, but in the immediate day-to-day, trying to ensure solid coordination of medication management from the inpatient to outpatient setting is likely to be very helpful for their patients.”
The long-term outcomes of hospitalized patients are largely influenced by getting them set up with appropriate community resources and supports once they leave the hospital, he added, and the hospital can play a critical role in putting these pieces into place.
Reference
1. Steinman MA. Reducing hospital admissions for adverse drug events through coordinated pharmacist care: learning from Hawai’i without a field trip. BMJ Qual Saf. Epub 2018 Nov 24. doi: 10.1136/bmjqs-2018-008815. Accessed Dec. 11, 2018.
Adverse drug reactions are a problem hospitalists encounter often. An estimated 9% of hospital admissions in older adults are the result of adverse drug reactions, and up to one in five adults experience an adverse drug reaction during hospitalization.
“Many interventions have been tried to solve this problem, and certain of them have worked, but to date we don’t have any great solutions that meaningfully impact the rate of these events in a way that’s feasible in most health care environments, so any efforts to reduce the burden of these problems in older adults could be hugely beneficial,” said Michael Steinman, MD, author of an editorial highlighting a new approach.
His editorial in BMJ Quality & Safety cites research on the Pharm2Pharm program, implemented in six Hawaiian hospitals, in which hospital-based pharmacists identified inpatients at high risk of medication misadventures with criteria such as use of multiple medications, presence of high-risk medications such as warfarin or glucose-lowering drugs, and a history of previous acute care use resulting from medication-related problems. The hospital pharmacist would then meet with the patient to reconcile medications and facilitate a coordinated hand-off to a community pharmacist, who would meet with the patient after discharge.
In addition to a 36% reduction in the rate of medication-related hospitalizations, the intervention generated an estimated savings of $6.6 million per year in avoided hospitalizations.
There are two major takeaways, said Dr. Steinman, who is based in the division of geriatrics at the University of California, San Francisco: It’s critical to focus on transitions and coordination between inpatient and outpatient care to address medication-related problems, and pharmacists can be extremely helpful in that.
“Decisions about drug therapy in the hospital may seem reasonable in the short term but often won’t stick in the long term unless there is a coordinated care that can help ensure appropriate follow-through once patients return home,” Dr. Steinman said. “The study that the editorial references is a systems intervention that hospitalists can advocate for in their own institutions, but in the immediate day-to-day, trying to ensure solid coordination of medication management from the inpatient to outpatient setting is likely to be very helpful for their patients.”
The long-term outcomes of hospitalized patients are largely influenced by getting them set up with appropriate community resources and supports once they leave the hospital, he added, and the hospital can play a critical role in putting these pieces into place.
Reference
1. Steinman MA. Reducing hospital admissions for adverse drug events through coordinated pharmacist care: learning from Hawai’i without a field trip. BMJ Qual Saf. Epub 2018 Nov 24. doi: 10.1136/bmjqs-2018-008815. Accessed Dec. 11, 2018.
Bringing QI training to an IM residency program
Consider a formal step-wise curriculum
For current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful practice. One physician team set out to provide their trainees with that QI foundation and described the results.
“We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also increase residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jacksonville, Fla.
Prior to any interventions, the team surveyed internal medicine residents regarding three unique patient scenarios and scored their answers. Residents were then assigned to one of five unique QI projects for the academic year in combination with a structured didactic QI curriculum.
After the structured progressive curriculum, in combination with team-based QI projects, residents were surveyed again. Results showed not only increased QI knowledge, but also improved patient safety and reduced waste.
“Keys to successful implementation included a thorough explanation of the need for this curriculum to the learners and ensuring that QI teams were multidisciplinary – residents, QI experts, nurses, techs, pharmacy, administrators, etc.,” said Dr. Cowdell.
For hospitalists in an academic setting, this work can provide a framework to incorporate QI into their residency programs. “I hope, if they have a passion for QI, they would seek out opportunities to mentor residents and help lead multidisciplinary team-based projects,” Dr. Cowdell said.
Reference
1. Cowdell, JC; Trautman, C; Lewis, M; Dawson, N. Integration of a Novel Quality Improvement Curriculum into an Internal Medicine Residency Program. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 54. https://www.shmabstracts.com/abstract/integration-of-a-novel-quality-improvement-curriculum-into-an-internal-medicine-residency-program/. Accessed Dec. 11, 2018.
Consider a formal step-wise curriculum
Consider a formal step-wise curriculum
For current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful practice. One physician team set out to provide their trainees with that QI foundation and described the results.
“We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also increase residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jacksonville, Fla.
Prior to any interventions, the team surveyed internal medicine residents regarding three unique patient scenarios and scored their answers. Residents were then assigned to one of five unique QI projects for the academic year in combination with a structured didactic QI curriculum.
After the structured progressive curriculum, in combination with team-based QI projects, residents were surveyed again. Results showed not only increased QI knowledge, but also improved patient safety and reduced waste.
“Keys to successful implementation included a thorough explanation of the need for this curriculum to the learners and ensuring that QI teams were multidisciplinary – residents, QI experts, nurses, techs, pharmacy, administrators, etc.,” said Dr. Cowdell.
For hospitalists in an academic setting, this work can provide a framework to incorporate QI into their residency programs. “I hope, if they have a passion for QI, they would seek out opportunities to mentor residents and help lead multidisciplinary team-based projects,” Dr. Cowdell said.
Reference
1. Cowdell, JC; Trautman, C; Lewis, M; Dawson, N. Integration of a Novel Quality Improvement Curriculum into an Internal Medicine Residency Program. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 54. https://www.shmabstracts.com/abstract/integration-of-a-novel-quality-improvement-curriculum-into-an-internal-medicine-residency-program/. Accessed Dec. 11, 2018.
For current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful practice. One physician team set out to provide their trainees with that QI foundation and described the results.
“We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also increase residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jacksonville, Fla.
Prior to any interventions, the team surveyed internal medicine residents regarding three unique patient scenarios and scored their answers. Residents were then assigned to one of five unique QI projects for the academic year in combination with a structured didactic QI curriculum.
After the structured progressive curriculum, in combination with team-based QI projects, residents were surveyed again. Results showed not only increased QI knowledge, but also improved patient safety and reduced waste.
“Keys to successful implementation included a thorough explanation of the need for this curriculum to the learners and ensuring that QI teams were multidisciplinary – residents, QI experts, nurses, techs, pharmacy, administrators, etc.,” said Dr. Cowdell.
For hospitalists in an academic setting, this work can provide a framework to incorporate QI into their residency programs. “I hope, if they have a passion for QI, they would seek out opportunities to mentor residents and help lead multidisciplinary team-based projects,” Dr. Cowdell said.
Reference
1. Cowdell, JC; Trautman, C; Lewis, M; Dawson, N. Integration of a Novel Quality Improvement Curriculum into an Internal Medicine Residency Program. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 54. https://www.shmabstracts.com/abstract/integration-of-a-novel-quality-improvement-curriculum-into-an-internal-medicine-residency-program/. Accessed Dec. 11, 2018.
New help for peanut allergies
Breakthrough therapy holds potential
When it comes to anaphylaxis episodes leading to pediatric intensive care–unit stays, peanuts are the most common culprit. Now the results of a recent clinical trial may lead to approval of the first oral medication to ameliorate reactions in children with severe peanut allergies.
After 6 months of treatment and 6 months of maintenance therapy, two-thirds of the 372 children who received this treatment could ingest the equivalent of two peanuts without allergic symptoms. Just 4% of the 124 children given a placebo powder were able to consume that amount of peanut without reacting. The treatment was not effective for the small number of adults in the study.
This trial of the drug, called AR101 and developed by Aimmune Therapeutics, was published in Nov. 2018 in the New England Journal of Medicine. The company has submitted a biologics license application to the U.S. Food and Drug Administration, and because the drug has been designated a breakthrough therapy, it will go through an accelerated approval process. It could be on the market by the end of 2019.
Reference
1. Rabin RC. New Peanut Allergy Drug Shows ‘Lifesaving’ Potential. New York Times. Nov. 18, 2018. https://www.nytimes.com/2018/11/18/well/live/new-peanut-allergy-drug-shows-lifesaving-potential.html. Accessed Nov. 26, 2018.
Breakthrough therapy holds potential
Breakthrough therapy holds potential
When it comes to anaphylaxis episodes leading to pediatric intensive care–unit stays, peanuts are the most common culprit. Now the results of a recent clinical trial may lead to approval of the first oral medication to ameliorate reactions in children with severe peanut allergies.
After 6 months of treatment and 6 months of maintenance therapy, two-thirds of the 372 children who received this treatment could ingest the equivalent of two peanuts without allergic symptoms. Just 4% of the 124 children given a placebo powder were able to consume that amount of peanut without reacting. The treatment was not effective for the small number of adults in the study.
This trial of the drug, called AR101 and developed by Aimmune Therapeutics, was published in Nov. 2018 in the New England Journal of Medicine. The company has submitted a biologics license application to the U.S. Food and Drug Administration, and because the drug has been designated a breakthrough therapy, it will go through an accelerated approval process. It could be on the market by the end of 2019.
Reference
1. Rabin RC. New Peanut Allergy Drug Shows ‘Lifesaving’ Potential. New York Times. Nov. 18, 2018. https://www.nytimes.com/2018/11/18/well/live/new-peanut-allergy-drug-shows-lifesaving-potential.html. Accessed Nov. 26, 2018.
When it comes to anaphylaxis episodes leading to pediatric intensive care–unit stays, peanuts are the most common culprit. Now the results of a recent clinical trial may lead to approval of the first oral medication to ameliorate reactions in children with severe peanut allergies.
After 6 months of treatment and 6 months of maintenance therapy, two-thirds of the 372 children who received this treatment could ingest the equivalent of two peanuts without allergic symptoms. Just 4% of the 124 children given a placebo powder were able to consume that amount of peanut without reacting. The treatment was not effective for the small number of adults in the study.
This trial of the drug, called AR101 and developed by Aimmune Therapeutics, was published in Nov. 2018 in the New England Journal of Medicine. The company has submitted a biologics license application to the U.S. Food and Drug Administration, and because the drug has been designated a breakthrough therapy, it will go through an accelerated approval process. It could be on the market by the end of 2019.
Reference
1. Rabin RC. New Peanut Allergy Drug Shows ‘Lifesaving’ Potential. New York Times. Nov. 18, 2018. https://www.nytimes.com/2018/11/18/well/live/new-peanut-allergy-drug-shows-lifesaving-potential.html. Accessed Nov. 26, 2018.
Quick Byte: Hope for HF patients
A new device shows promise for heart failure patients, according to a recent study.
In a trial, 614 patients with severe heart failure were randomly assigned to receive standard medical treatment and a MitraClip, which helps repair the damaged mitral valve, or to receive medical treatment alone.
Among those who received only medical treatment, 151 were hospitalized for heart failure in the ensuing 2 years and 61 died. Among those who got the device, 92 were hospitalized for heart failure during the same period and 28 died.
Reference
1. Kolata G. Tiny Device is a ‘Huge Advance’ for Treatment of Severe Heart Failure. New York Times. Sept 23, 2018. https://www.nytimes.com/2018/09/23/health/heart-failure-valve-repair-microclip.html. Accessed Oct 10, 2018.
A new device shows promise for heart failure patients, according to a recent study.
In a trial, 614 patients with severe heart failure were randomly assigned to receive standard medical treatment and a MitraClip, which helps repair the damaged mitral valve, or to receive medical treatment alone.
Among those who received only medical treatment, 151 were hospitalized for heart failure in the ensuing 2 years and 61 died. Among those who got the device, 92 were hospitalized for heart failure during the same period and 28 died.
Reference
1. Kolata G. Tiny Device is a ‘Huge Advance’ for Treatment of Severe Heart Failure. New York Times. Sept 23, 2018. https://www.nytimes.com/2018/09/23/health/heart-failure-valve-repair-microclip.html. Accessed Oct 10, 2018.
A new device shows promise for heart failure patients, according to a recent study.
In a trial, 614 patients with severe heart failure were randomly assigned to receive standard medical treatment and a MitraClip, which helps repair the damaged mitral valve, or to receive medical treatment alone.
Among those who received only medical treatment, 151 were hospitalized for heart failure in the ensuing 2 years and 61 died. Among those who got the device, 92 were hospitalized for heart failure during the same period and 28 died.
Reference
1. Kolata G. Tiny Device is a ‘Huge Advance’ for Treatment of Severe Heart Failure. New York Times. Sept 23, 2018. https://www.nytimes.com/2018/09/23/health/heart-failure-valve-repair-microclip.html. Accessed Oct 10, 2018.
The search for a life-changing innovation
It might be the ultimate medical innovation – an artificial heart – and generations of physicians have pursued it, a story told in “Ticker: The Quest to Create an Artificial Heart.”
Author Mimi Swartz feared this history was being forgotten. “The larger-than-life personalities – Dr. Michael DeBakey and Dr. Denton Cooley – were such dominant figures for more than 50 years; I couldn’t stand for that history to be lost,” she said. “Also, so many innovations happened in Houston, including the implantation of the first artificial heart and the development of the Left Ventricular Assist Device – I couldn’t stand for that information to be lost too.”
Writing this book taught her a lot about innovation in medicine, the trade-offs involved in medical progress, even who benefits most.
“One of the most important things to think about is how many of these high-tech devices we need, and who will get them – who will be able to afford them,” she said.
“Medical innovation over the last 50 years is a global, billion dollar business, fraught with pitfalls: legal, governmental, ethical, financial, and, finally, personal,” Ms. Swartz said. “A great invention that could save millions of lives can end up on the junk heap because a hedge fund lost interest, while another great invention moves forward, but was stolen from the lab of another researcher. The persistence required to bring a medical device to market is daunting. One inventor told me, ‘If I’d known what was going to happen, I never would have even started.’ ”
Reference
Swartz M. Ticker: The Quest to Create an Artificial Heart. New York: Penguin Random House, 2018.
It might be the ultimate medical innovation – an artificial heart – and generations of physicians have pursued it, a story told in “Ticker: The Quest to Create an Artificial Heart.”
Author Mimi Swartz feared this history was being forgotten. “The larger-than-life personalities – Dr. Michael DeBakey and Dr. Denton Cooley – were such dominant figures for more than 50 years; I couldn’t stand for that history to be lost,” she said. “Also, so many innovations happened in Houston, including the implantation of the first artificial heart and the development of the Left Ventricular Assist Device – I couldn’t stand for that information to be lost too.”
Writing this book taught her a lot about innovation in medicine, the trade-offs involved in medical progress, even who benefits most.
“One of the most important things to think about is how many of these high-tech devices we need, and who will get them – who will be able to afford them,” she said.
“Medical innovation over the last 50 years is a global, billion dollar business, fraught with pitfalls: legal, governmental, ethical, financial, and, finally, personal,” Ms. Swartz said. “A great invention that could save millions of lives can end up on the junk heap because a hedge fund lost interest, while another great invention moves forward, but was stolen from the lab of another researcher. The persistence required to bring a medical device to market is daunting. One inventor told me, ‘If I’d known what was going to happen, I never would have even started.’ ”
Reference
Swartz M. Ticker: The Quest to Create an Artificial Heart. New York: Penguin Random House, 2018.
It might be the ultimate medical innovation – an artificial heart – and generations of physicians have pursued it, a story told in “Ticker: The Quest to Create an Artificial Heart.”
Author Mimi Swartz feared this history was being forgotten. “The larger-than-life personalities – Dr. Michael DeBakey and Dr. Denton Cooley – were such dominant figures for more than 50 years; I couldn’t stand for that history to be lost,” she said. “Also, so many innovations happened in Houston, including the implantation of the first artificial heart and the development of the Left Ventricular Assist Device – I couldn’t stand for that information to be lost too.”
Writing this book taught her a lot about innovation in medicine, the trade-offs involved in medical progress, even who benefits most.
“One of the most important things to think about is how many of these high-tech devices we need, and who will get them – who will be able to afford them,” she said.
“Medical innovation over the last 50 years is a global, billion dollar business, fraught with pitfalls: legal, governmental, ethical, financial, and, finally, personal,” Ms. Swartz said. “A great invention that could save millions of lives can end up on the junk heap because a hedge fund lost interest, while another great invention moves forward, but was stolen from the lab of another researcher. The persistence required to bring a medical device to market is daunting. One inventor told me, ‘If I’d known what was going to happen, I never would have even started.’ ”
Reference
Swartz M. Ticker: The Quest to Create an Artificial Heart. New York: Penguin Random House, 2018.
Breaking the high-utilization cycle
Hospitalists know that a small percentage of patients account for a disproportionately large percentage of overall health care spending, much of which comes from inpatient admissions. Many programs have been developed around the country to work with this population, and most of these programs are – appropriately – outpatient based.
“However, a subset of frequently admitted patients either don’t make it to outpatient care or are unengaged with outpatient care and programs, for whom hospital stays can give us a unique opportunity to coordinate and streamline care, and to build trust that can then lead to increased patient engagement,” said Kirstin Knox, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and lead author of an abstract describing a method to address this challenge. “Our program works with these patients, the ‘outliers among the outliers’ to re-engage them in care, streamline admissions, coordinate inpatient and outpatient care, and address the underlying barriers/drivers that lead to frequent hospitalization.”
Their program designed and implemented a multidisciplinary intervention targeting the highest utilizers on their inpatient general medicine service. Each was assigned an inpatient continuity team, and the patient case was then presented to a multidisciplinary high-utilizer care committee that included physicians, nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management to develop a care plan.
Analysis comparing the 6 months before and after intervention showed admissions and total hospital days were reduced by 55% and 47% respectively, and 30-day readmissions were reduced by 65%. Total direct costs were reduced from $2,923,000 to $1,284,000.
The top takeaway, Dr. Knox said, is that, through efforts to coordinate care and address underlying drivers of high utilization, hospital-based programs for the most frequently admitted patients can streamline inpatient care and decrease utilization for many high-risk, high-cost patients.
“I hope that hospitalists will consider starting inpatient-based high-utilizer programs at their own institutions, if they haven’t already,” she said. “Even starting with one or two of your most frequently admitted patients can be incredibly eye opening, and streamlining/coordinating care (as well as working overtime to address the underlying drivers/barriers that lead to high utilization) for these patients is incredibly rewarding.”
Reference
Knox K et al. Breaking the cycle: a successful inpatient based intervention for hospital high utilizers. Abstract published at Hospital Medicine 2018; Apr 8-11; Orlando, Fla., Abstract 319. Accessed 2018 Oct 2.
Hospitalists know that a small percentage of patients account for a disproportionately large percentage of overall health care spending, much of which comes from inpatient admissions. Many programs have been developed around the country to work with this population, and most of these programs are – appropriately – outpatient based.
“However, a subset of frequently admitted patients either don’t make it to outpatient care or are unengaged with outpatient care and programs, for whom hospital stays can give us a unique opportunity to coordinate and streamline care, and to build trust that can then lead to increased patient engagement,” said Kirstin Knox, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and lead author of an abstract describing a method to address this challenge. “Our program works with these patients, the ‘outliers among the outliers’ to re-engage them in care, streamline admissions, coordinate inpatient and outpatient care, and address the underlying barriers/drivers that lead to frequent hospitalization.”
Their program designed and implemented a multidisciplinary intervention targeting the highest utilizers on their inpatient general medicine service. Each was assigned an inpatient continuity team, and the patient case was then presented to a multidisciplinary high-utilizer care committee that included physicians, nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management to develop a care plan.
Analysis comparing the 6 months before and after intervention showed admissions and total hospital days were reduced by 55% and 47% respectively, and 30-day readmissions were reduced by 65%. Total direct costs were reduced from $2,923,000 to $1,284,000.
The top takeaway, Dr. Knox said, is that, through efforts to coordinate care and address underlying drivers of high utilization, hospital-based programs for the most frequently admitted patients can streamline inpatient care and decrease utilization for many high-risk, high-cost patients.
“I hope that hospitalists will consider starting inpatient-based high-utilizer programs at their own institutions, if they haven’t already,” she said. “Even starting with one or two of your most frequently admitted patients can be incredibly eye opening, and streamlining/coordinating care (as well as working overtime to address the underlying drivers/barriers that lead to high utilization) for these patients is incredibly rewarding.”
Reference
Knox K et al. Breaking the cycle: a successful inpatient based intervention for hospital high utilizers. Abstract published at Hospital Medicine 2018; Apr 8-11; Orlando, Fla., Abstract 319. Accessed 2018 Oct 2.
Hospitalists know that a small percentage of patients account for a disproportionately large percentage of overall health care spending, much of which comes from inpatient admissions. Many programs have been developed around the country to work with this population, and most of these programs are – appropriately – outpatient based.
“However, a subset of frequently admitted patients either don’t make it to outpatient care or are unengaged with outpatient care and programs, for whom hospital stays can give us a unique opportunity to coordinate and streamline care, and to build trust that can then lead to increased patient engagement,” said Kirstin Knox, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and lead author of an abstract describing a method to address this challenge. “Our program works with these patients, the ‘outliers among the outliers’ to re-engage them in care, streamline admissions, coordinate inpatient and outpatient care, and address the underlying barriers/drivers that lead to frequent hospitalization.”
Their program designed and implemented a multidisciplinary intervention targeting the highest utilizers on their inpatient general medicine service. Each was assigned an inpatient continuity team, and the patient case was then presented to a multidisciplinary high-utilizer care committee that included physicians, nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management to develop a care plan.
Analysis comparing the 6 months before and after intervention showed admissions and total hospital days were reduced by 55% and 47% respectively, and 30-day readmissions were reduced by 65%. Total direct costs were reduced from $2,923,000 to $1,284,000.
The top takeaway, Dr. Knox said, is that, through efforts to coordinate care and address underlying drivers of high utilization, hospital-based programs for the most frequently admitted patients can streamline inpatient care and decrease utilization for many high-risk, high-cost patients.
“I hope that hospitalists will consider starting inpatient-based high-utilizer programs at their own institutions, if they haven’t already,” she said. “Even starting with one or two of your most frequently admitted patients can be incredibly eye opening, and streamlining/coordinating care (as well as working overtime to address the underlying drivers/barriers that lead to high utilization) for these patients is incredibly rewarding.”
Reference
Knox K et al. Breaking the cycle: a successful inpatient based intervention for hospital high utilizers. Abstract published at Hospital Medicine 2018; Apr 8-11; Orlando, Fla., Abstract 319. Accessed 2018 Oct 2.
Bringing hospitalist coverage to critical access hospitals
“As a hospitalist, I believe that my specialty improves care for inpatients,” said Ethan Kuperman, MD, MS, FHM, clinical associate professor of medicine at University of Iowa Health Care in Iowa City. “I want hospitalists involved with as many hospitals as possible because I believe we will lead to better patient outcomes.”
But, he adds, it’s not feasible to place dedicated hospitalists in every rural hospital in the United States – especially those running far below the average hospitalist census. “As a university, academic hospitalist, I wanted to make sure that the innovations and knowledge of the University of Iowa could penetrate into the greater community, and I wanted to strengthen the continuity of care between our partners in rural Iowa and our physical location in Iowa City,” he said.
Enter the virtual hospitalist: A telemedicine “virtual hospitalist” may expand capabilities at a fractional cost of an on-site provider.
Dr. Kuperman’s 6-month pilot program provided “virtual hospitalist” coverage to patients at a critical access hospital in rural Iowa.
“Our rural partners want to ensure that they are providing high-quality care within their communities and aren’t transferring patients without a good indication to larger centers,” he said. “For patients, this program means more of them can remain in their communities, surrounded by their families. I don’t think the virtual hospitalist program delivers equivalent care to the university hospital – I think we deliver better care because of that continuity with local providers and the ability of patients to remain in contact with their support structures.”
The study concludes that the virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally, and a single virtual hospitalist may be able to cover multiple critical access hospitals simultaneously.
“We have the technology to deliver hospitalist expertise to rural hospitals through telehealth in a way that benefits patients, rural hospitals, and academic hospitals,” he said.
Reference
Kuperman E et al. The Virtual Hospitalist: A single-site implementation bringing hospitalist coverage to critical access hospitals. Journal of Hospital Medicine. Published online first 2018 Sep 26. doi: 10.12788/jhm.3061. Accessed 2018 Oct 2.
“As a hospitalist, I believe that my specialty improves care for inpatients,” said Ethan Kuperman, MD, MS, FHM, clinical associate professor of medicine at University of Iowa Health Care in Iowa City. “I want hospitalists involved with as many hospitals as possible because I believe we will lead to better patient outcomes.”
But, he adds, it’s not feasible to place dedicated hospitalists in every rural hospital in the United States – especially those running far below the average hospitalist census. “As a university, academic hospitalist, I wanted to make sure that the innovations and knowledge of the University of Iowa could penetrate into the greater community, and I wanted to strengthen the continuity of care between our partners in rural Iowa and our physical location in Iowa City,” he said.
Enter the virtual hospitalist: A telemedicine “virtual hospitalist” may expand capabilities at a fractional cost of an on-site provider.
Dr. Kuperman’s 6-month pilot program provided “virtual hospitalist” coverage to patients at a critical access hospital in rural Iowa.
“Our rural partners want to ensure that they are providing high-quality care within their communities and aren’t transferring patients without a good indication to larger centers,” he said. “For patients, this program means more of them can remain in their communities, surrounded by their families. I don’t think the virtual hospitalist program delivers equivalent care to the university hospital – I think we deliver better care because of that continuity with local providers and the ability of patients to remain in contact with their support structures.”
The study concludes that the virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally, and a single virtual hospitalist may be able to cover multiple critical access hospitals simultaneously.
“We have the technology to deliver hospitalist expertise to rural hospitals through telehealth in a way that benefits patients, rural hospitals, and academic hospitals,” he said.
Reference
Kuperman E et al. The Virtual Hospitalist: A single-site implementation bringing hospitalist coverage to critical access hospitals. Journal of Hospital Medicine. Published online first 2018 Sep 26. doi: 10.12788/jhm.3061. Accessed 2018 Oct 2.
“As a hospitalist, I believe that my specialty improves care for inpatients,” said Ethan Kuperman, MD, MS, FHM, clinical associate professor of medicine at University of Iowa Health Care in Iowa City. “I want hospitalists involved with as many hospitals as possible because I believe we will lead to better patient outcomes.”
But, he adds, it’s not feasible to place dedicated hospitalists in every rural hospital in the United States – especially those running far below the average hospitalist census. “As a university, academic hospitalist, I wanted to make sure that the innovations and knowledge of the University of Iowa could penetrate into the greater community, and I wanted to strengthen the continuity of care between our partners in rural Iowa and our physical location in Iowa City,” he said.
Enter the virtual hospitalist: A telemedicine “virtual hospitalist” may expand capabilities at a fractional cost of an on-site provider.
Dr. Kuperman’s 6-month pilot program provided “virtual hospitalist” coverage to patients at a critical access hospital in rural Iowa.
“Our rural partners want to ensure that they are providing high-quality care within their communities and aren’t transferring patients without a good indication to larger centers,” he said. “For patients, this program means more of them can remain in their communities, surrounded by their families. I don’t think the virtual hospitalist program delivers equivalent care to the university hospital – I think we deliver better care because of that continuity with local providers and the ability of patients to remain in contact with their support structures.”
The study concludes that the virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally, and a single virtual hospitalist may be able to cover multiple critical access hospitals simultaneously.
“We have the technology to deliver hospitalist expertise to rural hospitals through telehealth in a way that benefits patients, rural hospitals, and academic hospitals,” he said.
Reference
Kuperman E et al. The Virtual Hospitalist: A single-site implementation bringing hospitalist coverage to critical access hospitals. Journal of Hospital Medicine. Published online first 2018 Sep 26. doi: 10.12788/jhm.3061. Accessed 2018 Oct 2.
Reducing sepsis mortality
The CDC estimates that 1.7 million people in the United States acquire sepsis annually; sepsis accounts for nearly 270,000 patient deaths per year.
Decreasing mortality and improving patient outcomes requires early detection and appropriate timely treatment. The Joint Commission Center for Transforming Healthcare’s recent sepsis project demonstrated this by analyzing root causes and reducing sepsis mortality with five leading hospitals by an aggregate of nearly 25%.
“Most organizations can tell you how they are doing with regard to whether or not they are ordering lactates or fluids, but many can’t tell you where in the process these elements are failing,” said Kelly Barnes, Black Belt III, Joint Commission Center for Transforming Healthcare. “For instance, is the issue in ordering lactates, drawing lactates, or getting the results of lactates in a timely manner? The key is to understand where in the process things are breaking down to identify what solutions an organization needs to put in place.”
During the Joint Commission project, one organization found that patients had inadequate fluid resuscitation due to staff fear of fluid overload, while another organization found they had issues with fluids being disconnected when patients were taken for tests and then not reconnected – different problems that needed different solutions.
The Joint Commission Center for Transforming Healthcare is currently developing a Targeted Solutions Tool® (TST®), scheduled for release in 2019, to help organizations determine their issues with sepsis recognition and barriers to meeting sepsis bundle element requirements and implement targeted solutions to address their specific issues. The tool will be available free of charge to all Joint Commission-accredited customers.
Reference
1. “Hospital-Wide Sepsis Project Reduces Mortality by Nearly 25 Percent,” Kelly Barnes, The Joint Commission Center for Transforming Healthcare. 2018, Sep 25.
The CDC estimates that 1.7 million people in the United States acquire sepsis annually; sepsis accounts for nearly 270,000 patient deaths per year.
Decreasing mortality and improving patient outcomes requires early detection and appropriate timely treatment. The Joint Commission Center for Transforming Healthcare’s recent sepsis project demonstrated this by analyzing root causes and reducing sepsis mortality with five leading hospitals by an aggregate of nearly 25%.
“Most organizations can tell you how they are doing with regard to whether or not they are ordering lactates or fluids, but many can’t tell you where in the process these elements are failing,” said Kelly Barnes, Black Belt III, Joint Commission Center for Transforming Healthcare. “For instance, is the issue in ordering lactates, drawing lactates, or getting the results of lactates in a timely manner? The key is to understand where in the process things are breaking down to identify what solutions an organization needs to put in place.”
During the Joint Commission project, one organization found that patients had inadequate fluid resuscitation due to staff fear of fluid overload, while another organization found they had issues with fluids being disconnected when patients were taken for tests and then not reconnected – different problems that needed different solutions.
The Joint Commission Center for Transforming Healthcare is currently developing a Targeted Solutions Tool® (TST®), scheduled for release in 2019, to help organizations determine their issues with sepsis recognition and barriers to meeting sepsis bundle element requirements and implement targeted solutions to address their specific issues. The tool will be available free of charge to all Joint Commission-accredited customers.
Reference
1. “Hospital-Wide Sepsis Project Reduces Mortality by Nearly 25 Percent,” Kelly Barnes, The Joint Commission Center for Transforming Healthcare. 2018, Sep 25.
The CDC estimates that 1.7 million people in the United States acquire sepsis annually; sepsis accounts for nearly 270,000 patient deaths per year.
Decreasing mortality and improving patient outcomes requires early detection and appropriate timely treatment. The Joint Commission Center for Transforming Healthcare’s recent sepsis project demonstrated this by analyzing root causes and reducing sepsis mortality with five leading hospitals by an aggregate of nearly 25%.
“Most organizations can tell you how they are doing with regard to whether or not they are ordering lactates or fluids, but many can’t tell you where in the process these elements are failing,” said Kelly Barnes, Black Belt III, Joint Commission Center for Transforming Healthcare. “For instance, is the issue in ordering lactates, drawing lactates, or getting the results of lactates in a timely manner? The key is to understand where in the process things are breaking down to identify what solutions an organization needs to put in place.”
During the Joint Commission project, one organization found that patients had inadequate fluid resuscitation due to staff fear of fluid overload, while another organization found they had issues with fluids being disconnected when patients were taken for tests and then not reconnected – different problems that needed different solutions.
The Joint Commission Center for Transforming Healthcare is currently developing a Targeted Solutions Tool® (TST®), scheduled for release in 2019, to help organizations determine their issues with sepsis recognition and barriers to meeting sepsis bundle element requirements and implement targeted solutions to address their specific issues. The tool will be available free of charge to all Joint Commission-accredited customers.
Reference
1. “Hospital-Wide Sepsis Project Reduces Mortality by Nearly 25 Percent,” Kelly Barnes, The Joint Commission Center for Transforming Healthcare. 2018, Sep 25.
Creating innovative discharge plans
‘Long Stay Committee’ may help
Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.
The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.
“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”
The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.
Reference
Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .
‘Long Stay Committee’ may help
‘Long Stay Committee’ may help
Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.
The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.
“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”
The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.
Reference
Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .
Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.
The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.
“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”
The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.
Reference
Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .
Highlighting the value in high-value care
Helping consumers learn
Hospitalists can have a role in helping patients choose and receive high-value care from the vast array of health care choices they face. Helping them use quality and cost reports is one way to do that, according to a recent editorial by Jeffrey T. Kullgren, MD, MS, MPH.
We know that if consumers used public reporting of quality and costs to choose facilities that generate the best health outcomes for the resources utilized, it might improve the overall value of health care spending. But most people choose health care services based on personal recommendations or the requirements of their insurance network. Even if they wanted to use reports of quality or cost, the information in these reports is meant for providers and would likely be unhelpful for consumers.
Research suggests that different presentation of the information could make a difference. “Simpler presentations of information in public reports may be more likely to help consumers choose higher-value providers and facilities,” Dr. Kullgren said.
He concluded that consumers may also need additional incentives, “such as financial incentives to encourage high-value choices or programs that educate consumers about how to use cost and quality information when seeking care,” he said.
There’s an opportunity for hospitalists to help consumers learn to use that information. “This strategy would approach consumerism as a teachable health behavior and could be particularly helpful for consumers with ongoing medical needs who face high cost sharing,” he wrote.
“Some hospitalists may be involved in the implementation of programs to publicly report quality and costs for their institutions,” he said. “Others may treat patients who have chosen hospitals based on publicly reported information, or patients who might be interested in using such information to choose sites of postdischarge outpatient care. In each of these cases, it is important for hospitalists to understand the opportunities and limits of such public reports so as to best help patients receive high-value care.”
Reference
Kullgren JT. Helping consumers make high value health care choices: The devil is in the details. Health Serv Res. 2018;53(4). http://www.hsr.org/hsr/abstract.jsp?aid=53301961729.
Helping consumers learn
Helping consumers learn
Hospitalists can have a role in helping patients choose and receive high-value care from the vast array of health care choices they face. Helping them use quality and cost reports is one way to do that, according to a recent editorial by Jeffrey T. Kullgren, MD, MS, MPH.
We know that if consumers used public reporting of quality and costs to choose facilities that generate the best health outcomes for the resources utilized, it might improve the overall value of health care spending. But most people choose health care services based on personal recommendations or the requirements of their insurance network. Even if they wanted to use reports of quality or cost, the information in these reports is meant for providers and would likely be unhelpful for consumers.
Research suggests that different presentation of the information could make a difference. “Simpler presentations of information in public reports may be more likely to help consumers choose higher-value providers and facilities,” Dr. Kullgren said.
He concluded that consumers may also need additional incentives, “such as financial incentives to encourage high-value choices or programs that educate consumers about how to use cost and quality information when seeking care,” he said.
There’s an opportunity for hospitalists to help consumers learn to use that information. “This strategy would approach consumerism as a teachable health behavior and could be particularly helpful for consumers with ongoing medical needs who face high cost sharing,” he wrote.
“Some hospitalists may be involved in the implementation of programs to publicly report quality and costs for their institutions,” he said. “Others may treat patients who have chosen hospitals based on publicly reported information, or patients who might be interested in using such information to choose sites of postdischarge outpatient care. In each of these cases, it is important for hospitalists to understand the opportunities and limits of such public reports so as to best help patients receive high-value care.”
Reference
Kullgren JT. Helping consumers make high value health care choices: The devil is in the details. Health Serv Res. 2018;53(4). http://www.hsr.org/hsr/abstract.jsp?aid=53301961729.
Hospitalists can have a role in helping patients choose and receive high-value care from the vast array of health care choices they face. Helping them use quality and cost reports is one way to do that, according to a recent editorial by Jeffrey T. Kullgren, MD, MS, MPH.
We know that if consumers used public reporting of quality and costs to choose facilities that generate the best health outcomes for the resources utilized, it might improve the overall value of health care spending. But most people choose health care services based on personal recommendations or the requirements of their insurance network. Even if they wanted to use reports of quality or cost, the information in these reports is meant for providers and would likely be unhelpful for consumers.
Research suggests that different presentation of the information could make a difference. “Simpler presentations of information in public reports may be more likely to help consumers choose higher-value providers and facilities,” Dr. Kullgren said.
He concluded that consumers may also need additional incentives, “such as financial incentives to encourage high-value choices or programs that educate consumers about how to use cost and quality information when seeking care,” he said.
There’s an opportunity for hospitalists to help consumers learn to use that information. “This strategy would approach consumerism as a teachable health behavior and could be particularly helpful for consumers with ongoing medical needs who face high cost sharing,” he wrote.
“Some hospitalists may be involved in the implementation of programs to publicly report quality and costs for their institutions,” he said. “Others may treat patients who have chosen hospitals based on publicly reported information, or patients who might be interested in using such information to choose sites of postdischarge outpatient care. In each of these cases, it is important for hospitalists to understand the opportunities and limits of such public reports so as to best help patients receive high-value care.”
Reference
Kullgren JT. Helping consumers make high value health care choices: The devil is in the details. Health Serv Res. 2018;53(4). http://www.hsr.org/hsr/abstract.jsp?aid=53301961729.