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Delving into the details
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
For my research project, we are looking to develop a tool that would use data from within 24 hours of a patient’s admission to the hospital to predict whether they will require post-acute care placement after discharge. While I have often been summarizing my project with this broad one-liner, in the last two weeks I have been delving more into the details of what exactly we mean by “data from within 24 hours of a patient’s admission.”
We are going through each of the variables systematically to take into account prior literature on how they were treated in other studies, as well as the practical limitations imposed by the data-gathering within our own system to choose how these values will be selected for each admission. My mentor Dr. Eduard Vasilevskis is helping me with making these decisions, based on the prototype model that was the inspiration for this project. Once we have identified all of the details of each variable we want to track, Dr. Jesse Ehrenfeld will be facilitating our use of the database.
Certainly this project has helped illuminate not only research-specific hurdles, but also underscores the fundamental difficulty of clinical decision-making in the first 24 hours of a patient’s admission. With data changing rapidly and sometimes incomplete data, clinicians need to quickly make care decisions that can impact a lot more than the patient’s post-discharge destination.
We anticipate that once we’ve made these choices, there will be further choices to make about how to treat these variables in the analysis. We hope to have the assistance of an experienced statistician to help guide us in making those decisions.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
For my research project, we are looking to develop a tool that would use data from within 24 hours of a patient’s admission to the hospital to predict whether they will require post-acute care placement after discharge. While I have often been summarizing my project with this broad one-liner, in the last two weeks I have been delving more into the details of what exactly we mean by “data from within 24 hours of a patient’s admission.”
We are going through each of the variables systematically to take into account prior literature on how they were treated in other studies, as well as the practical limitations imposed by the data-gathering within our own system to choose how these values will be selected for each admission. My mentor Dr. Eduard Vasilevskis is helping me with making these decisions, based on the prototype model that was the inspiration for this project. Once we have identified all of the details of each variable we want to track, Dr. Jesse Ehrenfeld will be facilitating our use of the database.
Certainly this project has helped illuminate not only research-specific hurdles, but also underscores the fundamental difficulty of clinical decision-making in the first 24 hours of a patient’s admission. With data changing rapidly and sometimes incomplete data, clinicians need to quickly make care decisions that can impact a lot more than the patient’s post-discharge destination.
We anticipate that once we’ve made these choices, there will be further choices to make about how to treat these variables in the analysis. We hope to have the assistance of an experienced statistician to help guide us in making those decisions.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
For my research project, we are looking to develop a tool that would use data from within 24 hours of a patient’s admission to the hospital to predict whether they will require post-acute care placement after discharge. While I have often been summarizing my project with this broad one-liner, in the last two weeks I have been delving more into the details of what exactly we mean by “data from within 24 hours of a patient’s admission.”
We are going through each of the variables systematically to take into account prior literature on how they were treated in other studies, as well as the practical limitations imposed by the data-gathering within our own system to choose how these values will be selected for each admission. My mentor Dr. Eduard Vasilevskis is helping me with making these decisions, based on the prototype model that was the inspiration for this project. Once we have identified all of the details of each variable we want to track, Dr. Jesse Ehrenfeld will be facilitating our use of the database.
Certainly this project has helped illuminate not only research-specific hurdles, but also underscores the fundamental difficulty of clinical decision-making in the first 24 hours of a patient’s admission. With data changing rapidly and sometimes incomplete data, clinicians need to quickly make care decisions that can impact a lot more than the patient’s post-discharge destination.
We anticipate that once we’ve made these choices, there will be further choices to make about how to treat these variables in the analysis. We hope to have the assistance of an experienced statistician to help guide us in making those decisions.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Inclusion valued by advanced practice providers
Editor’s note: Each month, the Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Lorraine Britting, ANP, SFHM, clinical director of advanced practice in cardiology medicine at Beth Israel Deaconess Medical Center, Boston. Ms. Britting has been an SHM member for over 10 years, has served on various SHM committees, and was one of the first nurse practitioners to earn the Senior Fellow in Hospital Medicine designation.
How did you become a hospital medicine nurse practitioner, and when did you join SHM?
I was a nurse working in a CCU and MICU for 19 years when I graduated from a master’s program as a nurse practitioner (NP) in adult care. I thought I was going to work in the outpatient side after graduation, but my experience was much more suited to hospital medicine.
My first job in 2004 was as a hospitalist in a very small community hospital affiliated with Beth Israel Deaconess Medical Center. I was the first NP to work as an inpatient provider there, which was challenging, but I had the opportunity to wear many hats and be involved with numerous quality initiatives that helped me grow as a provider and a leader. I was working as the clinical manager of three hospitalist programs under the director by the time I left. I now work in inpatient cardiology and am the director of advanced practice providers (APPs) for cardiology medicine. I joined SHM in 2005 when it was a small but rapidly growing society, and I started work on the NP/PA Committee. I was also involved in the Hospital Quality and Patient Safety Committee for 6 years and worked as a peer reviewer for the Journal of Hospital Medicine.
Describe your role on the Membership Committee. What is the committee currently working on?
I am finishing my 3rd year on the committee. In the last few months, we have been focusing on member engagement. We have collected information on why members choose to join SHM and what deters potential members from joining SHM and we are developing strategies to build and retain our membership. The Membership Committee also reviews Fellows applications and discusses modifications of requirements each year.
As an NP, I have unique insight into motivations for why other APPs would join SHM and which membership benefits are most valuable. I find that many APPs join SHM because they feel that SHM treats them as equals, not junior members, as in some other physician organizations.
What does the Senior Fellow in Hospital Medicine designation mean to you?
I am grateful that SHM allows all members to be a part of the Fellows program, and I was honored to be one of the first NPs to become a Senior Fellow. Many medical societies allow APPs to join but do not offer the opportunity to become Fellows.
The Senior Fellowship application was a rigorous process and required experience in multiple areas, including quality projects, hospital committees, SHM Annual Conference attendance, and other clinical and nonclinical work that advances the profession.
As a nurse practitioner, which SHM resources do you find most valuable?
As a specialist NP, it’s easy for me to be current in cardiology but harder to keep current in general medicine. I find the clinical information very helpful to keep me up to date on hospital medicine. The Journal of Hospital Medicine and The Hospitalist are must reads, and the Annual Conference is, of course, very informative. I also enjoy the conversations on the Hospital Medicine Exchange and feel that the Choosing Wisely campaign is an excellent contribution to the goal of cost containment in everyday practice.
One of the best features of SHM is that I can meet other clinicians from around the country and around the world who have innovations or novel ideas that I can bring back to my institution.
What advice do you have for nurse practitioners as their role in hospital medicine continues to evolve?
I say to my staff that they should always say yes. Yes to continuing education, yes to opportunities for growth and advancement, yes to promotions, yes to research, etc. Careers develop in nonlinear ways, and you have to follow the opportunities as they come.
Ms. Steele is the marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: Each month, the Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Lorraine Britting, ANP, SFHM, clinical director of advanced practice in cardiology medicine at Beth Israel Deaconess Medical Center, Boston. Ms. Britting has been an SHM member for over 10 years, has served on various SHM committees, and was one of the first nurse practitioners to earn the Senior Fellow in Hospital Medicine designation.
How did you become a hospital medicine nurse practitioner, and when did you join SHM?
I was a nurse working in a CCU and MICU for 19 years when I graduated from a master’s program as a nurse practitioner (NP) in adult care. I thought I was going to work in the outpatient side after graduation, but my experience was much more suited to hospital medicine.
My first job in 2004 was as a hospitalist in a very small community hospital affiliated with Beth Israel Deaconess Medical Center. I was the first NP to work as an inpatient provider there, which was challenging, but I had the opportunity to wear many hats and be involved with numerous quality initiatives that helped me grow as a provider and a leader. I was working as the clinical manager of three hospitalist programs under the director by the time I left. I now work in inpatient cardiology and am the director of advanced practice providers (APPs) for cardiology medicine. I joined SHM in 2005 when it was a small but rapidly growing society, and I started work on the NP/PA Committee. I was also involved in the Hospital Quality and Patient Safety Committee for 6 years and worked as a peer reviewer for the Journal of Hospital Medicine.
Describe your role on the Membership Committee. What is the committee currently working on?
I am finishing my 3rd year on the committee. In the last few months, we have been focusing on member engagement. We have collected information on why members choose to join SHM and what deters potential members from joining SHM and we are developing strategies to build and retain our membership. The Membership Committee also reviews Fellows applications and discusses modifications of requirements each year.
As an NP, I have unique insight into motivations for why other APPs would join SHM and which membership benefits are most valuable. I find that many APPs join SHM because they feel that SHM treats them as equals, not junior members, as in some other physician organizations.
What does the Senior Fellow in Hospital Medicine designation mean to you?
I am grateful that SHM allows all members to be a part of the Fellows program, and I was honored to be one of the first NPs to become a Senior Fellow. Many medical societies allow APPs to join but do not offer the opportunity to become Fellows.
The Senior Fellowship application was a rigorous process and required experience in multiple areas, including quality projects, hospital committees, SHM Annual Conference attendance, and other clinical and nonclinical work that advances the profession.
As a nurse practitioner, which SHM resources do you find most valuable?
As a specialist NP, it’s easy for me to be current in cardiology but harder to keep current in general medicine. I find the clinical information very helpful to keep me up to date on hospital medicine. The Journal of Hospital Medicine and The Hospitalist are must reads, and the Annual Conference is, of course, very informative. I also enjoy the conversations on the Hospital Medicine Exchange and feel that the Choosing Wisely campaign is an excellent contribution to the goal of cost containment in everyday practice.
One of the best features of SHM is that I can meet other clinicians from around the country and around the world who have innovations or novel ideas that I can bring back to my institution.
What advice do you have for nurse practitioners as their role in hospital medicine continues to evolve?
I say to my staff that they should always say yes. Yes to continuing education, yes to opportunities for growth and advancement, yes to promotions, yes to research, etc. Careers develop in nonlinear ways, and you have to follow the opportunities as they come.
Ms. Steele is the marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: Each month, the Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Lorraine Britting, ANP, SFHM, clinical director of advanced practice in cardiology medicine at Beth Israel Deaconess Medical Center, Boston. Ms. Britting has been an SHM member for over 10 years, has served on various SHM committees, and was one of the first nurse practitioners to earn the Senior Fellow in Hospital Medicine designation.
How did you become a hospital medicine nurse practitioner, and when did you join SHM?
I was a nurse working in a CCU and MICU for 19 years when I graduated from a master’s program as a nurse practitioner (NP) in adult care. I thought I was going to work in the outpatient side after graduation, but my experience was much more suited to hospital medicine.
My first job in 2004 was as a hospitalist in a very small community hospital affiliated with Beth Israel Deaconess Medical Center. I was the first NP to work as an inpatient provider there, which was challenging, but I had the opportunity to wear many hats and be involved with numerous quality initiatives that helped me grow as a provider and a leader. I was working as the clinical manager of three hospitalist programs under the director by the time I left. I now work in inpatient cardiology and am the director of advanced practice providers (APPs) for cardiology medicine. I joined SHM in 2005 when it was a small but rapidly growing society, and I started work on the NP/PA Committee. I was also involved in the Hospital Quality and Patient Safety Committee for 6 years and worked as a peer reviewer for the Journal of Hospital Medicine.
Describe your role on the Membership Committee. What is the committee currently working on?
I am finishing my 3rd year on the committee. In the last few months, we have been focusing on member engagement. We have collected information on why members choose to join SHM and what deters potential members from joining SHM and we are developing strategies to build and retain our membership. The Membership Committee also reviews Fellows applications and discusses modifications of requirements each year.
As an NP, I have unique insight into motivations for why other APPs would join SHM and which membership benefits are most valuable. I find that many APPs join SHM because they feel that SHM treats them as equals, not junior members, as in some other physician organizations.
What does the Senior Fellow in Hospital Medicine designation mean to you?
I am grateful that SHM allows all members to be a part of the Fellows program, and I was honored to be one of the first NPs to become a Senior Fellow. Many medical societies allow APPs to join but do not offer the opportunity to become Fellows.
The Senior Fellowship application was a rigorous process and required experience in multiple areas, including quality projects, hospital committees, SHM Annual Conference attendance, and other clinical and nonclinical work that advances the profession.
As a nurse practitioner, which SHM resources do you find most valuable?
As a specialist NP, it’s easy for me to be current in cardiology but harder to keep current in general medicine. I find the clinical information very helpful to keep me up to date on hospital medicine. The Journal of Hospital Medicine and The Hospitalist are must reads, and the Annual Conference is, of course, very informative. I also enjoy the conversations on the Hospital Medicine Exchange and feel that the Choosing Wisely campaign is an excellent contribution to the goal of cost containment in everyday practice.
One of the best features of SHM is that I can meet other clinicians from around the country and around the world who have innovations or novel ideas that I can bring back to my institution.
What advice do you have for nurse practitioners as their role in hospital medicine continues to evolve?
I say to my staff that they should always say yes. Yes to continuing education, yes to opportunities for growth and advancement, yes to promotions, yes to research, etc. Careers develop in nonlinear ways, and you have to follow the opportunities as they come.
Ms. Steele is the marketing communications specialist at the Society of Hospital Medicine.
Putting Choosing Wisely into practice
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
Observing BP measurement made no difference in SPRINT
ANAHEIM, CALIF. – More than half of the BP measurements of patients in the SPRINT trial were at least partially attended by clinic staff, but those efforts made no difference in outcomes, according to a survey presented by SPRINT investigators at the American Heart Association scientific sessions.
“It really didn’t matter” whether measurements were observed or not; blood pressure control and outcomes – fewer deaths and cardiovascular events when hypertension was treated to below 120 mm Hg instead of below 140 mm Hg – were largely the same either way, said the survey’s lead investigator Karen C. Johnson, MD, professor of women’s health and preventive medicine at the University of Tennessee in Memphis. 
What did matter were the other measures SPRINT [Systolic Blood Pressure Intervention Trial] took to ensure accurate blood pressure measurement, including patients resting for 5 minutes; three automated readings taken afterward then averaged; proper cuff size; feet flat on the floor while patients sat; arms at proper level, and no talking, texting, or filling out forms during the reading, Dr. Johnson said (N Engl J Med. 2015 Nov 26;373[22]:2103-16).
“If you do [those things], then it doesn’t matter if somebody is in the room or not; you can treat to the levels we are talking about,” said William Cushman, MD, professor of medicine and physiology at the university, and also a SPRINT investigator. 
Although the SPRINT researchers hadn’t addressed the issue before the AHA meeting, it’s been widely thought, and even reported in some places, that blood pressures in the trial were unattended. The misperception has led to anxiety about how to apply SPRINT to everyday practice, since few clinics are set up to have patients sit alone for 5 or 10 minutes for a blood pressure.
To address the concern, the SPRINT team surveyed study sites after the trial ended. It turned out that 4,082 subjects were at sites where patients were usually left alone for both the 5-minute rest period and the three BP readings, and 2,247 were at sites where staff usually attended both; 1,746 were at sites that left patients alone for the rest period only; and 570 were at sites where patients were alone only for the BP readings.
Observation had no impact on blood pressure. In the intensive arm, participants achieved and maintained an average systolic BP of about 120 mm Hg in all four groups. In the standard treatment arm, that average was about 135 mm Hg in all four groups. “When we look at the number of medications used, they were very similar in all four blood pressure groups,” with intensive treatment patients taking an average of one extra drug, Dr. Johnson said.
Intensive treatment, versus standard treatment, reduced cardiovascular events to a similar extent in patients who were alone for the entire blood pressure reading (by 38%) and those who were accompanied throughout (by 36%). For reasons that are not clear, intensive treatment did not significantly reduce risk among subjects who were observed during rest or observed for blood pressure readings. Both groups had lower Framingham 10-year cardiovascular disease risk scores, which may have been a confounder.
Meanwhile, the rate of adverse events and total mortality – lower with intensive treatment – did not vary by observation, Dr. Johnson said.
The survey excluded 716 subjects at 14 study sites who could not be classified into one of the four BP observation categories.
SPRINT was sponsored by the National Institutes of Health. Doctors Johnson and Cushman didn’t have any disclosures.
ANAHEIM, CALIF. – More than half of the BP measurements of patients in the SPRINT trial were at least partially attended by clinic staff, but those efforts made no difference in outcomes, according to a survey presented by SPRINT investigators at the American Heart Association scientific sessions.
“It really didn’t matter” whether measurements were observed or not; blood pressure control and outcomes – fewer deaths and cardiovascular events when hypertension was treated to below 120 mm Hg instead of below 140 mm Hg – were largely the same either way, said the survey’s lead investigator Karen C. Johnson, MD, professor of women’s health and preventive medicine at the University of Tennessee in Memphis.
What did matter were the other measures SPRINT [Systolic Blood Pressure Intervention Trial] took to ensure accurate blood pressure measurement, including patients resting for 5 minutes; three automated readings taken afterward then averaged; proper cuff size; feet flat on the floor while patients sat; arms at proper level, and no talking, texting, or filling out forms during the reading, Dr. Johnson said (N Engl J Med. 2015 Nov 26;373[22]:2103-16).
“If you do [those things], then it doesn’t matter if somebody is in the room or not; you can treat to the levels we are talking about,” said William Cushman, MD, professor of medicine and physiology at the university, and also a SPRINT investigator.
Although the SPRINT researchers hadn’t addressed the issue before the AHA meeting, it’s been widely thought, and even reported in some places, that blood pressures in the trial were unattended. The misperception has led to anxiety about how to apply SPRINT to everyday practice, since few clinics are set up to have patients sit alone for 5 or 10 minutes for a blood pressure.
To address the concern, the SPRINT team surveyed study sites after the trial ended. It turned out that 4,082 subjects were at sites where patients were usually left alone for both the 5-minute rest period and the three BP readings, and 2,247 were at sites where staff usually attended both; 1,746 were at sites that left patients alone for the rest period only; and 570 were at sites where patients were alone only for the BP readings.
Observation had no impact on blood pressure. In the intensive arm, participants achieved and maintained an average systolic BP of about 120 mm Hg in all four groups. In the standard treatment arm, that average was about 135 mm Hg in all four groups. “When we look at the number of medications used, they were very similar in all four blood pressure groups,” with intensive treatment patients taking an average of one extra drug, Dr. Johnson said.
Intensive treatment, versus standard treatment, reduced cardiovascular events to a similar extent in patients who were alone for the entire blood pressure reading (by 38%) and those who were accompanied throughout (by 36%). For reasons that are not clear, intensive treatment did not significantly reduce risk among subjects who were observed during rest or observed for blood pressure readings. Both groups had lower Framingham 10-year cardiovascular disease risk scores, which may have been a confounder.
Meanwhile, the rate of adverse events and total mortality – lower with intensive treatment – did not vary by observation, Dr. Johnson said.
The survey excluded 716 subjects at 14 study sites who could not be classified into one of the four BP observation categories.
SPRINT was sponsored by the National Institutes of Health. Doctors Johnson and Cushman didn’t have any disclosures.
ANAHEIM, CALIF. – More than half of the BP measurements of patients in the SPRINT trial were at least partially attended by clinic staff, but those efforts made no difference in outcomes, according to a survey presented by SPRINT investigators at the American Heart Association scientific sessions.
“It really didn’t matter” whether measurements were observed or not; blood pressure control and outcomes – fewer deaths and cardiovascular events when hypertension was treated to below 120 mm Hg instead of below 140 mm Hg – were largely the same either way, said the survey’s lead investigator Karen C. Johnson, MD, professor of women’s health and preventive medicine at the University of Tennessee in Memphis.
What did matter were the other measures SPRINT [Systolic Blood Pressure Intervention Trial] took to ensure accurate blood pressure measurement, including patients resting for 5 minutes; three automated readings taken afterward then averaged; proper cuff size; feet flat on the floor while patients sat; arms at proper level, and no talking, texting, or filling out forms during the reading, Dr. Johnson said (N Engl J Med. 2015 Nov 26;373[22]:2103-16).
“If you do [those things], then it doesn’t matter if somebody is in the room or not; you can treat to the levels we are talking about,” said William Cushman, MD, professor of medicine and physiology at the university, and also a SPRINT investigator.
Although the SPRINT researchers hadn’t addressed the issue before the AHA meeting, it’s been widely thought, and even reported in some places, that blood pressures in the trial were unattended. The misperception has led to anxiety about how to apply SPRINT to everyday practice, since few clinics are set up to have patients sit alone for 5 or 10 minutes for a blood pressure.
To address the concern, the SPRINT team surveyed study sites after the trial ended. It turned out that 4,082 subjects were at sites where patients were usually left alone for both the 5-minute rest period and the three BP readings, and 2,247 were at sites where staff usually attended both; 1,746 were at sites that left patients alone for the rest period only; and 570 were at sites where patients were alone only for the BP readings.
Observation had no impact on blood pressure. In the intensive arm, participants achieved and maintained an average systolic BP of about 120 mm Hg in all four groups. In the standard treatment arm, that average was about 135 mm Hg in all four groups. “When we look at the number of medications used, they were very similar in all four blood pressure groups,” with intensive treatment patients taking an average of one extra drug, Dr. Johnson said.
Intensive treatment, versus standard treatment, reduced cardiovascular events to a similar extent in patients who were alone for the entire blood pressure reading (by 38%) and those who were accompanied throughout (by 36%). For reasons that are not clear, intensive treatment did not significantly reduce risk among subjects who were observed during rest or observed for blood pressure readings. Both groups had lower Framingham 10-year cardiovascular disease risk scores, which may have been a confounder.
Meanwhile, the rate of adverse events and total mortality – lower with intensive treatment – did not vary by observation, Dr. Johnson said.
The survey excluded 716 subjects at 14 study sites who could not be classified into one of the four BP observation categories.
SPRINT was sponsored by the National Institutes of Health. Doctors Johnson and Cushman didn’t have any disclosures.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: Blood pressure and CV event reductions were similar in the 4,082 subjects at sites where patients were usually left alone for both the 5-minute rest period and the three BP readings, the 2,247 patients at sites where staff usually attended both, the 1,746 at sites that left patients alone for the rest period only, and the 570 at sites where patients were alone only for the BP readings.
Data source: A survey of SPRINT study sites.
Disclosures: SPRINT was sponsored by the National Institutes of Health. The presenter had no disclosures.
Sneak Peek: The Hospital Leader blog – Nov. 2017
What we expect and what we get from work
Are American workers becoming happier with less? An interesting article in the Wall Street Journal reported on the findings of a recent survey of U.S. workers by the Conference Board, a research organization. Although the survey wasn’t specific to health care, much less to hospitalists, I see some parallels that might cause many of us to stop and think more carefully about what we expect from our work.
American workers today tend to have less job security and fewer employer-paid benefits than they did in previous generations. A companion graphic in the WSJ reported that, while in 1973 only 6% of Americans said they worked too many hours and 7% said they had trouble completing their work in the time allotted, by 2016 26% said they often worked more than 48 hours a week and half said they work during their free time at least periodically. Two-thirds of Americans now say they need to spend at least half of their day working at high speeds or meeting tight deadlines.
Yet, despite these trends, the Conference Board found that overall, U.S. workers are more satisfied with their jobs than they have been in the past. The WSJ article posits that workers are happier at work because they have adjusted to lower expectations of the employer-employee relationship. In addition, workers have more flexibility today to change jobs or companies to find the right fit or pursue advancement, and often have more influence over when, where, and how they do their jobs than ever before. Many are working as temps or independent contractors, or in similar “contingent” arrangements. Finally, more employers are offering a wider array of tools to aid with work-life balance, such as paid medical and family leave.
So what does all this have to do with hospitalists?
Read the full post at hospitalleader.org.
Also on The Hospital Leader…
- 95% of inpatient providers would get an F on this exam by Brad Flansbaum, DO, MPH, MHM
- When it comes to health care violence, silence isn’t an option by Danielle Scheurer, MD, MSCR, SFHM,
- How do we keep our providers safe? by Tracy Cardin, ACNP-BC, SFHM
- We have a voice. It’s time we use it #DoctorsSpeakOut by Vineet Arora, MD, MAPP, MHM
What we expect and what we get from work
Are American workers becoming happier with less? An interesting article in the Wall Street Journal reported on the findings of a recent survey of U.S. workers by the Conference Board, a research organization. Although the survey wasn’t specific to health care, much less to hospitalists, I see some parallels that might cause many of us to stop and think more carefully about what we expect from our work.
American workers today tend to have less job security and fewer employer-paid benefits than they did in previous generations. A companion graphic in the WSJ reported that, while in 1973 only 6% of Americans said they worked too many hours and 7% said they had trouble completing their work in the time allotted, by 2016 26% said they often worked more than 48 hours a week and half said they work during their free time at least periodically. Two-thirds of Americans now say they need to spend at least half of their day working at high speeds or meeting tight deadlines.
Yet, despite these trends, the Conference Board found that overall, U.S. workers are more satisfied with their jobs than they have been in the past. The WSJ article posits that workers are happier at work because they have adjusted to lower expectations of the employer-employee relationship. In addition, workers have more flexibility today to change jobs or companies to find the right fit or pursue advancement, and often have more influence over when, where, and how they do their jobs than ever before. Many are working as temps or independent contractors, or in similar “contingent” arrangements. Finally, more employers are offering a wider array of tools to aid with work-life balance, such as paid medical and family leave.
So what does all this have to do with hospitalists?
Read the full post at hospitalleader.org.
Also on The Hospital Leader…
- 95% of inpatient providers would get an F on this exam by Brad Flansbaum, DO, MPH, MHM
- When it comes to health care violence, silence isn’t an option by Danielle Scheurer, MD, MSCR, SFHM,
- How do we keep our providers safe? by Tracy Cardin, ACNP-BC, SFHM
- We have a voice. It’s time we use it #DoctorsSpeakOut by Vineet Arora, MD, MAPP, MHM
What we expect and what we get from work
Are American workers becoming happier with less? An interesting article in the Wall Street Journal reported on the findings of a recent survey of U.S. workers by the Conference Board, a research organization. Although the survey wasn’t specific to health care, much less to hospitalists, I see some parallels that might cause many of us to stop and think more carefully about what we expect from our work.
American workers today tend to have less job security and fewer employer-paid benefits than they did in previous generations. A companion graphic in the WSJ reported that, while in 1973 only 6% of Americans said they worked too many hours and 7% said they had trouble completing their work in the time allotted, by 2016 26% said they often worked more than 48 hours a week and half said they work during their free time at least periodically. Two-thirds of Americans now say they need to spend at least half of their day working at high speeds or meeting tight deadlines.
Yet, despite these trends, the Conference Board found that overall, U.S. workers are more satisfied with their jobs than they have been in the past. The WSJ article posits that workers are happier at work because they have adjusted to lower expectations of the employer-employee relationship. In addition, workers have more flexibility today to change jobs or companies to find the right fit or pursue advancement, and often have more influence over when, where, and how they do their jobs than ever before. Many are working as temps or independent contractors, or in similar “contingent” arrangements. Finally, more employers are offering a wider array of tools to aid with work-life balance, such as paid medical and family leave.
So what does all this have to do with hospitalists?
Read the full post at hospitalleader.org.
Also on The Hospital Leader…
- 95% of inpatient providers would get an F on this exam by Brad Flansbaum, DO, MPH, MHM
- When it comes to health care violence, silence isn’t an option by Danielle Scheurer, MD, MSCR, SFHM,
- How do we keep our providers safe? by Tracy Cardin, ACNP-BC, SFHM
- We have a voice. It’s time we use it #DoctorsSpeakOut by Vineet Arora, MD, MAPP, MHM
Physicians do not trust bone biopsy culture data
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
As I approach the end of my summer research project, my team and I have reflected on what we’ve learned from both the research itself and the experience of working on the project.
As work-life balance is important to me, I would usually I would balk at the idea of sacrificing my personal time, but in this case, I am driven by a sense of ownership and pride over the project that I haven’t felt with past projects. I truly believe the results of this research have the potential to change the way physicians think about and manage patients with osteomyelitis, and I am eager to publish our results and attend conferences where I can present and discuss the findings with the medical community.
We hypothesized that the use of image-guided bone biopsies in patients with non-vertebral osteomyelitis would not have a significant impact on antibiotic management. Our results showed that physicians usually do not trust culture data provided by bone biopsy results. Negative bone cultures almost never lead physicians to discontinue antibiotics due to the low yield and reliability of bone biopsy culture data. Similarly, positive cultures almost never lead physicians to prescribe targeted antibiotics. 75% of the patients in our study had contiguous osteomyelitis caused by an overlying ulcer (e.g., diabetic foot ulcers or sacral decubitus ulcers). Exposure of the wound to the outside world often results in polymicrobial infections, and as such physicians rarely narrowed antibiotic coverage when a single organism was cultured. We also found that empiric antibiotic therapy adequately treated cultured micro-organisms in 95% of cases.
While many questions remained unanswered by this study, our results are an important contribution to the body of evidence that image-guided bone biopsies have low utility in the management of contiguous non-vertebral osteomyelitis. I look forward to seeing how the results of future research will compare with our findings. I am grateful to have had the opportunity to work in such an exciting area of research and I hope to continue participating in research projects throughout my medical career.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
As I approach the end of my summer research project, my team and I have reflected on what we’ve learned from both the research itself and the experience of working on the project.
As work-life balance is important to me, I would usually I would balk at the idea of sacrificing my personal time, but in this case, I am driven by a sense of ownership and pride over the project that I haven’t felt with past projects. I truly believe the results of this research have the potential to change the way physicians think about and manage patients with osteomyelitis, and I am eager to publish our results and attend conferences where I can present and discuss the findings with the medical community.
We hypothesized that the use of image-guided bone biopsies in patients with non-vertebral osteomyelitis would not have a significant impact on antibiotic management. Our results showed that physicians usually do not trust culture data provided by bone biopsy results. Negative bone cultures almost never lead physicians to discontinue antibiotics due to the low yield and reliability of bone biopsy culture data. Similarly, positive cultures almost never lead physicians to prescribe targeted antibiotics. 75% of the patients in our study had contiguous osteomyelitis caused by an overlying ulcer (e.g., diabetic foot ulcers or sacral decubitus ulcers). Exposure of the wound to the outside world often results in polymicrobial infections, and as such physicians rarely narrowed antibiotic coverage when a single organism was cultured. We also found that empiric antibiotic therapy adequately treated cultured micro-organisms in 95% of cases.
While many questions remained unanswered by this study, our results are an important contribution to the body of evidence that image-guided bone biopsies have low utility in the management of contiguous non-vertebral osteomyelitis. I look forward to seeing how the results of future research will compare with our findings. I am grateful to have had the opportunity to work in such an exciting area of research and I hope to continue participating in research projects throughout my medical career.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
As I approach the end of my summer research project, my team and I have reflected on what we’ve learned from both the research itself and the experience of working on the project.
As work-life balance is important to me, I would usually I would balk at the idea of sacrificing my personal time, but in this case, I am driven by a sense of ownership and pride over the project that I haven’t felt with past projects. I truly believe the results of this research have the potential to change the way physicians think about and manage patients with osteomyelitis, and I am eager to publish our results and attend conferences where I can present and discuss the findings with the medical community.
We hypothesized that the use of image-guided bone biopsies in patients with non-vertebral osteomyelitis would not have a significant impact on antibiotic management. Our results showed that physicians usually do not trust culture data provided by bone biopsy results. Negative bone cultures almost never lead physicians to discontinue antibiotics due to the low yield and reliability of bone biopsy culture data. Similarly, positive cultures almost never lead physicians to prescribe targeted antibiotics. 75% of the patients in our study had contiguous osteomyelitis caused by an overlying ulcer (e.g., diabetic foot ulcers or sacral decubitus ulcers). Exposure of the wound to the outside world often results in polymicrobial infections, and as such physicians rarely narrowed antibiotic coverage when a single organism was cultured. We also found that empiric antibiotic therapy adequately treated cultured micro-organisms in 95% of cases.
While many questions remained unanswered by this study, our results are an important contribution to the body of evidence that image-guided bone biopsies have low utility in the management of contiguous non-vertebral osteomyelitis. I look forward to seeing how the results of future research will compare with our findings. I am grateful to have had the opportunity to work in such an exciting area of research and I hope to continue participating in research projects throughout my medical career.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Reducing harm: When doing less is enough
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.” 
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Improving the risk assessment of patients with acute pulmonary embolism
Who doesn’t like alphabet soup? Those noodles shaped as letters floating in a delicious hot broth serve as an educational way for young children to play with their food. Of course, this commentary is not about warm food suitable for a cold day but, instead, about another notion of alphabet soup – a metaphor for physicians’ failure to optimally utilize our alphabet soup of venous thromboembolism studies.
The medical literature that has studied the incidence, prevalence, diagnosis, and management of acute pulmonary embolism (PE) is vast. Yes, we have our own PE “alphabet soup” – a “hodgepodge especially of initials,” according to the Merriam-Webster Dictionary. ICOPER (International Cooperative Pulmonary Embolism Registry) and RIETE (Computerized Registry of Patients with Venous Thromboembolism) help estimate prevalence of the disease and indicate high-risk groups. PESI (Pulmonary Embolism Severity Index) and PERC (Pulmonary Embolism Rule-Out Criteria) provide useful predictive information prior to proceeding with diagnostic testing for PE. The PEITHO (Pulmonary Embolism Thrombolysis), MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis), and PERFECT (Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis) studies help to guide the decision to administer fibrinolytic therapy, particularly in the cases of so-called submassive or intermediate-risk PE.
And yet, in a study published in Hospital Practice (2017 Aug 30. doi: 10.1080/21548331.2017.1372033), my colleagues and I showed that, to a large extent, physicians admitting patients to the hospital between 2011 and 2013 for acute PE failed to order or perform even the most basic noninvasive testing on their patients, despite strong recommendations for such testing from both the 2011 American Heart Association (AHA) and the 2014 European Society of Cardiology as part of the risk assessment of acute PE.
At the time of the patients’ PE admissions, the 2011 AHA statement already had been published, and it was recognized that medical and interventional therapies needed to be appropriate to the characteristics of the patient with PE. Specifically, in order to determine a prognosis, assessment of right heart strain with an echocardiogram, ECG, and brain natriuretic peptide testing was recommended. For similar reasons, a serum troponin test was recommended to evaluate any myocardial necrosis.
While the 2011 AHA statement was based on a preponderance of evidence-based medicine, our research suggests that physicians may be doing a suboptimal job of collecting the necessary data to manage our acute PE patients. In defense of those physicians we evaluated, these data were collected just before the European Society of Cardiology disseminated their recommendations for risk stratification in 2014. The PEITHO, MOPETT, and PERFECT findings – though already presented at medical meetings in part – were not published in scientific journals in full until 2013 or thereafter.
Nevertheless, I believe these findings illustrate the merits of the Pulmonary Embolism Response Team (PERT) concept. As the data we studied suggest, not only might hospital-based physicians inadequately assess the severity of patients’ PE, but they also may fail to ask for consultations from the specialists who could be most useful in assisting in the proper evaluation and management of these patients. PERTs ensure that every patient admitted to the hospital with the diagnosis of PE will be assessed by a team of physicians with the expertise and professional interest in best managing these patients.
The expectation is that, with the institution of a PERT at each hospital, a more complete evaluation of patients’ PE may lead to optimal management and, thereby, to improved short- and long-term outcomes. Also, we should not assume that a greater degree of expertise and imaging capabilities at an academic university hospital translates to a more complete evaluation of PE; our research shows that this is not necessarily the case. PERTs may help mobilize resources that are underutilized even at academic university hospitals. Those interested in learning more about PERTs may contact the National PERT Consortium via email at [email protected] or go online to www.pertconsortium.org.
Rather than wallow in an alphabet soup of acronyms, let us place our acronymic clinical PE trials to good use. Gather the appropriate clinical data, consult experts in pulmonary embolism, and stratify patients admitted to the hospital with acute PE so that we can manage the expectations of short- and long-term outcomes.
When he became president in 1933, Franklin D. Roosevelt sought to lift the United States from the Great Depression, in part with a New Deal “alphabet soup” of programs. Like FDR, let us put our own alphabet soup – of PE studies and position statements – to good use: to work for the good of people hospitalized with acute pulmonary embolism.
Dr. Scharf is medical director of pulmonary outpatient services at the Jane and Leonard Korman Respiratory Institute at Jefferson Medical College, Philadelphia. He is also director of the pulmonary vascular disease program at Jefferson.
Who doesn’t like alphabet soup? Those noodles shaped as letters floating in a delicious hot broth serve as an educational way for young children to play with their food. Of course, this commentary is not about warm food suitable for a cold day but, instead, about another notion of alphabet soup – a metaphor for physicians’ failure to optimally utilize our alphabet soup of venous thromboembolism studies.
The medical literature that has studied the incidence, prevalence, diagnosis, and management of acute pulmonary embolism (PE) is vast. Yes, we have our own PE “alphabet soup” – a “hodgepodge especially of initials,” according to the Merriam-Webster Dictionary. ICOPER (International Cooperative Pulmonary Embolism Registry) and RIETE (Computerized Registry of Patients with Venous Thromboembolism) help estimate prevalence of the disease and indicate high-risk groups. PESI (Pulmonary Embolism Severity Index) and PERC (Pulmonary Embolism Rule-Out Criteria) provide useful predictive information prior to proceeding with diagnostic testing for PE. The PEITHO (Pulmonary Embolism Thrombolysis), MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis), and PERFECT (Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis) studies help to guide the decision to administer fibrinolytic therapy, particularly in the cases of so-called submassive or intermediate-risk PE.
And yet, in a study published in Hospital Practice (2017 Aug 30. doi: 10.1080/21548331.2017.1372033), my colleagues and I showed that, to a large extent, physicians admitting patients to the hospital between 2011 and 2013 for acute PE failed to order or perform even the most basic noninvasive testing on their patients, despite strong recommendations for such testing from both the 2011 American Heart Association (AHA) and the 2014 European Society of Cardiology as part of the risk assessment of acute PE.
At the time of the patients’ PE admissions, the 2011 AHA statement already had been published, and it was recognized that medical and interventional therapies needed to be appropriate to the characteristics of the patient with PE. Specifically, in order to determine a prognosis, assessment of right heart strain with an echocardiogram, ECG, and brain natriuretic peptide testing was recommended. For similar reasons, a serum troponin test was recommended to evaluate any myocardial necrosis.
While the 2011 AHA statement was based on a preponderance of evidence-based medicine, our research suggests that physicians may be doing a suboptimal job of collecting the necessary data to manage our acute PE patients. In defense of those physicians we evaluated, these data were collected just before the European Society of Cardiology disseminated their recommendations for risk stratification in 2014. The PEITHO, MOPETT, and PERFECT findings – though already presented at medical meetings in part – were not published in scientific journals in full until 2013 or thereafter.
Nevertheless, I believe these findings illustrate the merits of the Pulmonary Embolism Response Team (PERT) concept. As the data we studied suggest, not only might hospital-based physicians inadequately assess the severity of patients’ PE, but they also may fail to ask for consultations from the specialists who could be most useful in assisting in the proper evaluation and management of these patients. PERTs ensure that every patient admitted to the hospital with the diagnosis of PE will be assessed by a team of physicians with the expertise and professional interest in best managing these patients.
The expectation is that, with the institution of a PERT at each hospital, a more complete evaluation of patients’ PE may lead to optimal management and, thereby, to improved short- and long-term outcomes. Also, we should not assume that a greater degree of expertise and imaging capabilities at an academic university hospital translates to a more complete evaluation of PE; our research shows that this is not necessarily the case. PERTs may help mobilize resources that are underutilized even at academic university hospitals. Those interested in learning more about PERTs may contact the National PERT Consortium via email at [email protected] or go online to www.pertconsortium.org.
Rather than wallow in an alphabet soup of acronyms, let us place our acronymic clinical PE trials to good use. Gather the appropriate clinical data, consult experts in pulmonary embolism, and stratify patients admitted to the hospital with acute PE so that we can manage the expectations of short- and long-term outcomes.
When he became president in 1933, Franklin D. Roosevelt sought to lift the United States from the Great Depression, in part with a New Deal “alphabet soup” of programs. Like FDR, let us put our own alphabet soup – of PE studies and position statements – to good use: to work for the good of people hospitalized with acute pulmonary embolism.
Dr. Scharf is medical director of pulmonary outpatient services at the Jane and Leonard Korman Respiratory Institute at Jefferson Medical College, Philadelphia. He is also director of the pulmonary vascular disease program at Jefferson.
Who doesn’t like alphabet soup? Those noodles shaped as letters floating in a delicious hot broth serve as an educational way for young children to play with their food. Of course, this commentary is not about warm food suitable for a cold day but, instead, about another notion of alphabet soup – a metaphor for physicians’ failure to optimally utilize our alphabet soup of venous thromboembolism studies.
The medical literature that has studied the incidence, prevalence, diagnosis, and management of acute pulmonary embolism (PE) is vast. Yes, we have our own PE “alphabet soup” – a “hodgepodge especially of initials,” according to the Merriam-Webster Dictionary. ICOPER (International Cooperative Pulmonary Embolism Registry) and RIETE (Computerized Registry of Patients with Venous Thromboembolism) help estimate prevalence of the disease and indicate high-risk groups. PESI (Pulmonary Embolism Severity Index) and PERC (Pulmonary Embolism Rule-Out Criteria) provide useful predictive information prior to proceeding with diagnostic testing for PE. The PEITHO (Pulmonary Embolism Thrombolysis), MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis), and PERFECT (Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis) studies help to guide the decision to administer fibrinolytic therapy, particularly in the cases of so-called submassive or intermediate-risk PE.
And yet, in a study published in Hospital Practice (2017 Aug 30. doi: 10.1080/21548331.2017.1372033), my colleagues and I showed that, to a large extent, physicians admitting patients to the hospital between 2011 and 2013 for acute PE failed to order or perform even the most basic noninvasive testing on their patients, despite strong recommendations for such testing from both the 2011 American Heart Association (AHA) and the 2014 European Society of Cardiology as part of the risk assessment of acute PE.
At the time of the patients’ PE admissions, the 2011 AHA statement already had been published, and it was recognized that medical and interventional therapies needed to be appropriate to the characteristics of the patient with PE. Specifically, in order to determine a prognosis, assessment of right heart strain with an echocardiogram, ECG, and brain natriuretic peptide testing was recommended. For similar reasons, a serum troponin test was recommended to evaluate any myocardial necrosis.
While the 2011 AHA statement was based on a preponderance of evidence-based medicine, our research suggests that physicians may be doing a suboptimal job of collecting the necessary data to manage our acute PE patients. In defense of those physicians we evaluated, these data were collected just before the European Society of Cardiology disseminated their recommendations for risk stratification in 2014. The PEITHO, MOPETT, and PERFECT findings – though already presented at medical meetings in part – were not published in scientific journals in full until 2013 or thereafter.
Nevertheless, I believe these findings illustrate the merits of the Pulmonary Embolism Response Team (PERT) concept. As the data we studied suggest, not only might hospital-based physicians inadequately assess the severity of patients’ PE, but they also may fail to ask for consultations from the specialists who could be most useful in assisting in the proper evaluation and management of these patients. PERTs ensure that every patient admitted to the hospital with the diagnosis of PE will be assessed by a team of physicians with the expertise and professional interest in best managing these patients.
The expectation is that, with the institution of a PERT at each hospital, a more complete evaluation of patients’ PE may lead to optimal management and, thereby, to improved short- and long-term outcomes. Also, we should not assume that a greater degree of expertise and imaging capabilities at an academic university hospital translates to a more complete evaluation of PE; our research shows that this is not necessarily the case. PERTs may help mobilize resources that are underutilized even at academic university hospitals. Those interested in learning more about PERTs may contact the National PERT Consortium via email at [email protected] or go online to www.pertconsortium.org.
Rather than wallow in an alphabet soup of acronyms, let us place our acronymic clinical PE trials to good use. Gather the appropriate clinical data, consult experts in pulmonary embolism, and stratify patients admitted to the hospital with acute PE so that we can manage the expectations of short- and long-term outcomes.
When he became president in 1933, Franklin D. Roosevelt sought to lift the United States from the Great Depression, in part with a New Deal “alphabet soup” of programs. Like FDR, let us put our own alphabet soup – of PE studies and position statements – to good use: to work for the good of people hospitalized with acute pulmonary embolism.
Dr. Scharf is medical director of pulmonary outpatient services at the Jane and Leonard Korman Respiratory Institute at Jefferson Medical College, Philadelphia. He is also director of the pulmonary vascular disease program at Jefferson.
How hospitalists can focus on health equity
A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
But today?
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
References
1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.
A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
But today?
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
References
1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.
A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
But today?
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
References
1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.
Journal of Hospital Medicine – Nov. 2017
BACKGROUND AND OBJECTIVES: Adherence to American Academy of Pediatrics (AAP) bronchiolitis clinical practice guideline recommendations improved significantly through the AAP’s multi-institutional collaborative the Bronchiolitis Quality Improvement Project (BQIP). We assessed sustainability of improvements at participating institutions for 1 year following completion of the collaborative.
METHODS: Twenty-one multidisciplinary hospital-based teams provided monthly data for key inpatient bronchiolitis measures during baseline and intervention bronchiolitis seasons. Nine sites provided data in the season following completion of the collaborative. Encounters included children younger than 24 months who were hospitalized for bronchiolitis without comorbid chronic illness, prematurity, or intensive care. Changes between baseline-, intervention-, and sustainability-season data were assessed using generalized linear mixed-effects models with site-specific random effects. Differences between hospital characteristics, baseline performance, and initial improvement among sites that did and did not participate in the sustainability season were compared.
RESULTS: A total of 2,275 discharges were reviewed, comprising 995 baseline, 877 intervention, and 403 sustainability-season encounters. Improvements in all key bronchiolitis quality measures achieved during the intervention season were maintained during the sustainability season, and orders for intermittent pulse oximetry increased from 40.6% (95% confidence interval, 22.8-61.1) to 79.2% (95% CI, 58.0-91.3). Sites that did and did not participate in the sustainability season had similar characteristics.
DISCUSSION: BQIP participating sites maintained improvements in key bronchiolitis quality measures for 1 year following the project’s completion. This approach, which provided an evidence-based best-practice toolkit while building the quality-improvement capacity of local interdisciplinary teams, may support performance gains that persist beyond the active phase of the collaborative.
Also in JHM this month
The effect of an inpatient smoking cessation treatment program on hospital readmissions and length of stayAUTHORS: Eline M. van den Broek-Altenburg, MS, MA, Adam J. Atherly, PhD
Treatment trends and outcomes in healthcare-associated pneumoniaAUTHORS: Sarah Haessler, MD; Tara Lagu, MD, MPH; Peter K. Lindenauer, MD, MSc; Daniel J. Skiest, MD; Aruna Priya, MA, MSc; Penelope S. Pekow, PhD; Marya D. Zilberberg, MD, MPH; Thomas L. Higgins, MD, MBA; Michael B. Rothberg, MD, MPH
What’s the purpose of rounds? A qualitative study examining the perceptions of faculty and studentsAUTHORS: Oliver Hulland; Jeanne Farnan, MD, MHPE; Raphael Rabinowitz; Lisa Kearns, MD, MS; Michele Long, MD; Bradley Monash, MD; Priti Bhansali, MD; H. Barrett Fromme, MD, MHPE
Association between anemia and fatigue in hospitalized patients: does the measure of anemia matter?AUTHORS: Micah T. Prochaska, MD, MS; Richard Newcomb, BA; Graham Block, BA; Brian Park, BA; David O. Meltzer MD, PhD
Helping seniors plan for posthospital discharge needs before a hospitalization occurs: Results from the randomized control trial of planyourlifespan.orgAUTHORS: Lee A. Lindquist, MD, MPH, MBA; Vanessa Ramirez-Zohfeld, MPH; Priya D. Sunkara, MA; Chris Forcucci, RN, BSN; Dianne S. Campbell, BS; Phyllis Mitzen, MA; Jody D. Ciolino, PhD; Gayle Kricke, MSW; Anne Seltzer, LSW; Ana V. Ramirez, BA; Kenzie A. Cameron, PhD, MPH
BACKGROUND AND OBJECTIVES: Adherence to American Academy of Pediatrics (AAP) bronchiolitis clinical practice guideline recommendations improved significantly through the AAP’s multi-institutional collaborative the Bronchiolitis Quality Improvement Project (BQIP). We assessed sustainability of improvements at participating institutions for 1 year following completion of the collaborative.
METHODS: Twenty-one multidisciplinary hospital-based teams provided monthly data for key inpatient bronchiolitis measures during baseline and intervention bronchiolitis seasons. Nine sites provided data in the season following completion of the collaborative. Encounters included children younger than 24 months who were hospitalized for bronchiolitis without comorbid chronic illness, prematurity, or intensive care. Changes between baseline-, intervention-, and sustainability-season data were assessed using generalized linear mixed-effects models with site-specific random effects. Differences between hospital characteristics, baseline performance, and initial improvement among sites that did and did not participate in the sustainability season were compared.
RESULTS: A total of 2,275 discharges were reviewed, comprising 995 baseline, 877 intervention, and 403 sustainability-season encounters. Improvements in all key bronchiolitis quality measures achieved during the intervention season were maintained during the sustainability season, and orders for intermittent pulse oximetry increased from 40.6% (95% confidence interval, 22.8-61.1) to 79.2% (95% CI, 58.0-91.3). Sites that did and did not participate in the sustainability season had similar characteristics.
DISCUSSION: BQIP participating sites maintained improvements in key bronchiolitis quality measures for 1 year following the project’s completion. This approach, which provided an evidence-based best-practice toolkit while building the quality-improvement capacity of local interdisciplinary teams, may support performance gains that persist beyond the active phase of the collaborative.
Also in JHM this month
The effect of an inpatient smoking cessation treatment program on hospital readmissions and length of stayAUTHORS: Eline M. van den Broek-Altenburg, MS, MA, Adam J. Atherly, PhD
Treatment trends and outcomes in healthcare-associated pneumoniaAUTHORS: Sarah Haessler, MD; Tara Lagu, MD, MPH; Peter K. Lindenauer, MD, MSc; Daniel J. Skiest, MD; Aruna Priya, MA, MSc; Penelope S. Pekow, PhD; Marya D. Zilberberg, MD, MPH; Thomas L. Higgins, MD, MBA; Michael B. Rothberg, MD, MPH
What’s the purpose of rounds? A qualitative study examining the perceptions of faculty and studentsAUTHORS: Oliver Hulland; Jeanne Farnan, MD, MHPE; Raphael Rabinowitz; Lisa Kearns, MD, MS; Michele Long, MD; Bradley Monash, MD; Priti Bhansali, MD; H. Barrett Fromme, MD, MHPE
Association between anemia and fatigue in hospitalized patients: does the measure of anemia matter?AUTHORS: Micah T. Prochaska, MD, MS; Richard Newcomb, BA; Graham Block, BA; Brian Park, BA; David O. Meltzer MD, PhD
Helping seniors plan for posthospital discharge needs before a hospitalization occurs: Results from the randomized control trial of planyourlifespan.orgAUTHORS: Lee A. Lindquist, MD, MPH, MBA; Vanessa Ramirez-Zohfeld, MPH; Priya D. Sunkara, MA; Chris Forcucci, RN, BSN; Dianne S. Campbell, BS; Phyllis Mitzen, MA; Jody D. Ciolino, PhD; Gayle Kricke, MSW; Anne Seltzer, LSW; Ana V. Ramirez, BA; Kenzie A. Cameron, PhD, MPH
BACKGROUND AND OBJECTIVES: Adherence to American Academy of Pediatrics (AAP) bronchiolitis clinical practice guideline recommendations improved significantly through the AAP’s multi-institutional collaborative the Bronchiolitis Quality Improvement Project (BQIP). We assessed sustainability of improvements at participating institutions for 1 year following completion of the collaborative.
METHODS: Twenty-one multidisciplinary hospital-based teams provided monthly data for key inpatient bronchiolitis measures during baseline and intervention bronchiolitis seasons. Nine sites provided data in the season following completion of the collaborative. Encounters included children younger than 24 months who were hospitalized for bronchiolitis without comorbid chronic illness, prematurity, or intensive care. Changes between baseline-, intervention-, and sustainability-season data were assessed using generalized linear mixed-effects models with site-specific random effects. Differences between hospital characteristics, baseline performance, and initial improvement among sites that did and did not participate in the sustainability season were compared.
RESULTS: A total of 2,275 discharges were reviewed, comprising 995 baseline, 877 intervention, and 403 sustainability-season encounters. Improvements in all key bronchiolitis quality measures achieved during the intervention season were maintained during the sustainability season, and orders for intermittent pulse oximetry increased from 40.6% (95% confidence interval, 22.8-61.1) to 79.2% (95% CI, 58.0-91.3). Sites that did and did not participate in the sustainability season had similar characteristics.
DISCUSSION: BQIP participating sites maintained improvements in key bronchiolitis quality measures for 1 year following the project’s completion. This approach, which provided an evidence-based best-practice toolkit while building the quality-improvement capacity of local interdisciplinary teams, may support performance gains that persist beyond the active phase of the collaborative.
Also in JHM this month
The effect of an inpatient smoking cessation treatment program on hospital readmissions and length of stayAUTHORS: Eline M. van den Broek-Altenburg, MS, MA, Adam J. Atherly, PhD
Treatment trends and outcomes in healthcare-associated pneumoniaAUTHORS: Sarah Haessler, MD; Tara Lagu, MD, MPH; Peter K. Lindenauer, MD, MSc; Daniel J. Skiest, MD; Aruna Priya, MA, MSc; Penelope S. Pekow, PhD; Marya D. Zilberberg, MD, MPH; Thomas L. Higgins, MD, MBA; Michael B. Rothberg, MD, MPH
What’s the purpose of rounds? A qualitative study examining the perceptions of faculty and studentsAUTHORS: Oliver Hulland; Jeanne Farnan, MD, MHPE; Raphael Rabinowitz; Lisa Kearns, MD, MS; Michele Long, MD; Bradley Monash, MD; Priti Bhansali, MD; H. Barrett Fromme, MD, MHPE
Association between anemia and fatigue in hospitalized patients: does the measure of anemia matter?AUTHORS: Micah T. Prochaska, MD, MS; Richard Newcomb, BA; Graham Block, BA; Brian Park, BA; David O. Meltzer MD, PhD
Helping seniors plan for posthospital discharge needs before a hospitalization occurs: Results from the randomized control trial of planyourlifespan.orgAUTHORS: Lee A. Lindquist, MD, MPH, MBA; Vanessa Ramirez-Zohfeld, MPH; Priya D. Sunkara, MA; Chris Forcucci, RN, BSN; Dianne S. Campbell, BS; Phyllis Mitzen, MA; Jody D. Ciolino, PhD; Gayle Kricke, MSW; Anne Seltzer, LSW; Ana V. Ramirez, BA; Kenzie A. Cameron, PhD, MPH