The Hospitalist

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

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

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

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

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

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

Last month, SHM presented live webinars on two of its signature mentored implementation programs that continue to change the way hospitals manage readmissions and glycemic control.

Find out how Project BOOST can help your hospital reduce preventable readmissions, decrease average length of stay, and improve patient satisfaction with one year of individualized mentoring from a physician leader. Watch the webinar at www.hospitalmedicine.org/BOOST.

Another signature program, SHM’s Glycemic Control Mentored Implementation program, has supported the development and implementation of glycemic control in more than 100 hospitals nationwide; added benefits include data collection and analysis tools, monthly coaching calls with mentors, SHM-facilitated calls, and more. View the free webinar to learn more at www.hospitalmedicine.org/gc.

Last month, SHM presented live webinars on two of its signature mentored implementation programs that continue to change the way hospitals manage readmissions and glycemic control.

Find out how Project BOOST can help your hospital reduce preventable readmissions, decrease average length of stay, and improve patient satisfaction with one year of individualized mentoring from a physician leader. Watch the webinar at www.hospitalmedicine.org/BOOST.

Another signature program, SHM’s Glycemic Control Mentored Implementation program, has supported the development and implementation of glycemic control in more than 100 hospitals nationwide; added benefits include data collection and analysis tools, monthly coaching calls with mentors, SHM-facilitated calls, and more. View the free webinar to learn more at www.hospitalmedicine.org/gc.

Last month, SHM presented live webinars on two of its signature mentored implementation programs that continue to change the way hospitals manage readmissions and glycemic control.

Find out how Project BOOST can help your hospital reduce preventable readmissions, decrease average length of stay, and improve patient satisfaction with one year of individualized mentoring from a physician leader. Watch the webinar at www.hospitalmedicine.org/BOOST.

Another signature program, SHM’s Glycemic Control Mentored Implementation program, has supported the development and implementation of glycemic control in more than 100 hospitals nationwide; added benefits include data collection and analysis tools, monthly coaching calls with mentors, SHM-facilitated calls, and more. View the free webinar to learn more at www.hospitalmedicine.org/gc.

Register now. Pediatric Hospital Medicine (PHM) 2016 is the premier educational conference for pediatric hospitalists and other clinicians involved in the care of hospitalized children. This year, PHM 2016 will be held at the Hyatt Regency Chicago in Illinois from July 28 to 31. For the latest information, visit www.phmmeeting.org.

Register now. Pediatric Hospital Medicine (PHM) 2016 is the premier educational conference for pediatric hospitalists and other clinicians involved in the care of hospitalized children. This year, PHM 2016 will be held at the Hyatt Regency Chicago in Illinois from July 28 to 31. For the latest information, visit www.phmmeeting.org.

Register now. Pediatric Hospital Medicine (PHM) 2016 is the premier educational conference for pediatric hospitalists and other clinicians involved in the care of hospitalized children. This year, PHM 2016 will be held at the Hyatt Regency Chicago in Illinois from July 28 to 31. For the latest information, visit www.phmmeeting.org.

NEW YORK (Reuters Health) - Older patients with the inflammatory skin disorder rosacea appear significantly more likely to be diagnosed with dementia, according to Danish researchers.

As Dr. Alexander Egeberg told Reuters Health by email, "We found an increased risk of dementia, in particular Alzheimer's disease (AD), in patients with rosacea. The risk was only increased in patients older than 60 years, however."

"Emerging data," he added, "suggest a link between rosacea and neurological disorders. Yet, it is important for patients to remember that the absolute risk is still low."

In an April 28 online paper in Annals of Neurology, Dr. Egeberg, of the University of Copenhagen, and colleagues note that in rosacea there's upregulation of various inflammatory mediators, for example, cytokines, antimicrobial peptides (AMPs), chemokines, and matrix metalloproteinases (MMPs). Similar processes appear to be at work in certain neurodegenerative disorders.

To examine the possible relationship, the team studied data from 1997 to 2012 on almost 5.6 million Danes. Of these, 82,439 had rosacea at baseline. Over a maximum follow-up of 16 years, 99,040 developed dementia, of whom 29,193 were diagnosed with AD.

After adjustment, patients with rosacea were at significantly increased risk of dementia (hazard ratio 1.07) and of AD (HR 1.25). Women were at greater risk of AD (HR 1.28) than men (HR 1.16).

However, stratification by age at study entry showed that the risk of AD was significantly increased only in those enrolled at the age of 60 or more (HR 1.20). When analyses were limited to patients with a hospital dermatologist diagnosis of rosacea, the HR for dementia was 1.42 and for AD it was 1.92.

The current sum of evidence, conclude the investigators,"suggests that certain forms of dementia, in particular AD, have prominent inflammatory components, and MMPs and AMPs may provide mechanistic links for the observed association between rosacea and dementia."

"Increased focus on symptoms of cognitive dysfunction in patients with rosacea may be warranted," they say.

The authors reported no funding or disclosures.

NEW YORK (Reuters Health) - Older patients with the inflammatory skin disorder rosacea appear significantly more likely to be diagnosed with dementia, according to Danish researchers.

As Dr. Alexander Egeberg told Reuters Health by email, "We found an increased risk of dementia, in particular Alzheimer's disease (AD), in patients with rosacea. The risk was only increased in patients older than 60 years, however."

"Emerging data," he added, "suggest a link between rosacea and neurological disorders. Yet, it is important for patients to remember that the absolute risk is still low."

In an April 28 online paper in Annals of Neurology, Dr. Egeberg, of the University of Copenhagen, and colleagues note that in rosacea there's upregulation of various inflammatory mediators, for example, cytokines, antimicrobial peptides (AMPs), chemokines, and matrix metalloproteinases (MMPs). Similar processes appear to be at work in certain neurodegenerative disorders.

To examine the possible relationship, the team studied data from 1997 to 2012 on almost 5.6 million Danes. Of these, 82,439 had rosacea at baseline. Over a maximum follow-up of 16 years, 99,040 developed dementia, of whom 29,193 were diagnosed with AD.

After adjustment, patients with rosacea were at significantly increased risk of dementia (hazard ratio 1.07) and of AD (HR 1.25). Women were at greater risk of AD (HR 1.28) than men (HR 1.16).

However, stratification by age at study entry showed that the risk of AD was significantly increased only in those enrolled at the age of 60 or more (HR 1.20). When analyses were limited to patients with a hospital dermatologist diagnosis of rosacea, the HR for dementia was 1.42 and for AD it was 1.92.

The current sum of evidence, conclude the investigators,"suggests that certain forms of dementia, in particular AD, have prominent inflammatory components, and MMPs and AMPs may provide mechanistic links for the observed association between rosacea and dementia."

"Increased focus on symptoms of cognitive dysfunction in patients with rosacea may be warranted," they say.

The authors reported no funding or disclosures.

NEW YORK (Reuters Health) - Older patients with the inflammatory skin disorder rosacea appear significantly more likely to be diagnosed with dementia, according to Danish researchers.

As Dr. Alexander Egeberg told Reuters Health by email, "We found an increased risk of dementia, in particular Alzheimer's disease (AD), in patients with rosacea. The risk was only increased in patients older than 60 years, however."

"Emerging data," he added, "suggest a link between rosacea and neurological disorders. Yet, it is important for patients to remember that the absolute risk is still low."

In an April 28 online paper in Annals of Neurology, Dr. Egeberg, of the University of Copenhagen, and colleagues note that in rosacea there's upregulation of various inflammatory mediators, for example, cytokines, antimicrobial peptides (AMPs), chemokines, and matrix metalloproteinases (MMPs). Similar processes appear to be at work in certain neurodegenerative disorders.

To examine the possible relationship, the team studied data from 1997 to 2012 on almost 5.6 million Danes. Of these, 82,439 had rosacea at baseline. Over a maximum follow-up of 16 years, 99,040 developed dementia, of whom 29,193 were diagnosed with AD.

After adjustment, patients with rosacea were at significantly increased risk of dementia (hazard ratio 1.07) and of AD (HR 1.25). Women were at greater risk of AD (HR 1.28) than men (HR 1.16).

However, stratification by age at study entry showed that the risk of AD was significantly increased only in those enrolled at the age of 60 or more (HR 1.20). When analyses were limited to patients with a hospital dermatologist diagnosis of rosacea, the HR for dementia was 1.42 and for AD it was 1.92.

The current sum of evidence, conclude the investigators,"suggests that certain forms of dementia, in particular AD, have prominent inflammatory components, and MMPs and AMPs may provide mechanistic links for the observed association between rosacea and dementia."

"Increased focus on symptoms of cognitive dysfunction in patients with rosacea may be warranted," they say.

The authors reported no funding or disclosures.

Clinical question: What strategies are effective in reducing contrast-induced nephropathy?

Bottom line: N-acetylcysteine plus intravenous fluids alone or in combination with a statin can prevent contrast-induced nephropathy (CIN). However, the strength of the evidence for these interventions is low. (LOE = 1b)

Reference: Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy. Ann Intern Med 2016;164(6):406-416.

Study design: Systematic review

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (ward only)

Synopsis

CIN is defined as an increase in serum creatinine of more than 25% or 0.5 mg/dL (44.2 umol/L) within 3 days of intravenous contrast administration. These investigators searched MEDLINE, EMBASE, and the Cochrane Library along with reference lists of relevant articles to find studies that evaluated use of N-acetylcysteine, sodium bicarbonate, sodium chloride, statins, or ascorbic acid to prevent CIN.

Two reviewers independently screened articles for eligibility, assessed each study's risk of bias, and graded the strength of evidence (SOE) for different comparisons. A total of 86 randomized controlled trials examining different strategies for CIN prevention were included. Ultimately, only 3 strategies were shown to have both a clinically important and statistically significant benefit: (1) low-dose N-acetylcysteine plus intravenous (IV) saline versus IV saline alone (pooled relative risk [RR] 0.75; 95% CI 0.63-0.89; low SOE), (2) N-acetylcysteine plus IV saline versus IV saline alone in patients receiving low-osmolar contrast media (pooled RR 0.69; 0.58-0.84; moderate SOE), and (3) statin plus N-acetylcysteine versus N-acetylcysteine alone (pooled RR 0.52; 0.29-0.93; low SOE). There were no statistically significant benefits seen with sodium bicarbonate or ascorbic acid.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: What strategies are effective in reducing contrast-induced nephropathy?

Bottom line: N-acetylcysteine plus intravenous fluids alone or in combination with a statin can prevent contrast-induced nephropathy (CIN). However, the strength of the evidence for these interventions is low. (LOE = 1b)

Reference: Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy. Ann Intern Med 2016;164(6):406-416.

Study design: Systematic review

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (ward only)

Synopsis

CIN is defined as an increase in serum creatinine of more than 25% or 0.5 mg/dL (44.2 umol/L) within 3 days of intravenous contrast administration. These investigators searched MEDLINE, EMBASE, and the Cochrane Library along with reference lists of relevant articles to find studies that evaluated use of N-acetylcysteine, sodium bicarbonate, sodium chloride, statins, or ascorbic acid to prevent CIN.

Two reviewers independently screened articles for eligibility, assessed each study's risk of bias, and graded the strength of evidence (SOE) for different comparisons. A total of 86 randomized controlled trials examining different strategies for CIN prevention were included. Ultimately, only 3 strategies were shown to have both a clinically important and statistically significant benefit: (1) low-dose N-acetylcysteine plus intravenous (IV) saline versus IV saline alone (pooled relative risk [RR] 0.75; 95% CI 0.63-0.89; low SOE), (2) N-acetylcysteine plus IV saline versus IV saline alone in patients receiving low-osmolar contrast media (pooled RR 0.69; 0.58-0.84; moderate SOE), and (3) statin plus N-acetylcysteine versus N-acetylcysteine alone (pooled RR 0.52; 0.29-0.93; low SOE). There were no statistically significant benefits seen with sodium bicarbonate or ascorbic acid.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: What strategies are effective in reducing contrast-induced nephropathy?

Bottom line: N-acetylcysteine plus intravenous fluids alone or in combination with a statin can prevent contrast-induced nephropathy (CIN). However, the strength of the evidence for these interventions is low. (LOE = 1b)

Reference: Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy. Ann Intern Med 2016;164(6):406-416.

Study design: Systematic review

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (ward only)

Synopsis

CIN is defined as an increase in serum creatinine of more than 25% or 0.5 mg/dL (44.2 umol/L) within 3 days of intravenous contrast administration. These investigators searched MEDLINE, EMBASE, and the Cochrane Library along with reference lists of relevant articles to find studies that evaluated use of N-acetylcysteine, sodium bicarbonate, sodium chloride, statins, or ascorbic acid to prevent CIN.

Two reviewers independently screened articles for eligibility, assessed each study's risk of bias, and graded the strength of evidence (SOE) for different comparisons. A total of 86 randomized controlled trials examining different strategies for CIN prevention were included. Ultimately, only 3 strategies were shown to have both a clinically important and statistically significant benefit: (1) low-dose N-acetylcysteine plus intravenous (IV) saline versus IV saline alone (pooled relative risk [RR] 0.75; 95% CI 0.63-0.89; low SOE), (2) N-acetylcysteine plus IV saline versus IV saline alone in patients receiving low-osmolar contrast media (pooled RR 0.69; 0.58-0.84; moderate SOE), and (3) statin plus N-acetylcysteine versus N-acetylcysteine alone (pooled RR 0.52; 0.29-0.93; low SOE). There were no statistically significant benefits seen with sodium bicarbonate or ascorbic acid.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of high-flow oxygen therapy for 24 hours following extubation reduce the risk of reintubation in low-risk patients?

Bottom line: Using high-flow nasal cannula oxygen therapy for 24 hours following extubation of patients who are already at low risk of reintubation further reduces the risk of reintubation. You would need to treat 14 patients with high-flow therapy to prevent reintubation in one patient. (LOE = 1b)

Reference: Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA 2016;315(13):1354-1361.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis

These investigators recruited mechanically ventilated adult patients who were ready for extubation and who met the criteria for low risk for reintubation. Low risk was defined as: younger than 65 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score of less than 12; fewer than 2 comorbidities; body mass index of less than 30; ability to manage secretions; simple weaning; and the absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency issues, and prolonged mechanical ventilation.

Using concealed allocation, these patients were randomized to receive either conventional oxygen therapy or high-flow oxygen therapy for 24 hours following extubation. Conventional oxygen therapy was continued in both groups after 24 hours as needed. The 2 groups had a mean age of 51 years and similar APACHE scores at baseline. The use of high-flow oxygen therapy reduced the rate of reintubation within 72 hours from 12.2% to 4.9% (absolute difference 7.2%; 95% CI 2.5%-12.2%; number needed to treat [NNT] = 14; P = .004). There were no significant differences detected in the 2 groups in secondary outcomes including time to reintubation or hospital length of stay. Notably, the study population had a high proportion of surgical and neurocritical patients, resulting in one-third of the reintubations occurring because of nonrespiratory causes such as repeat surgery or altered mental status. When the analysis was limited to only the respiratory-related intubations, the reduced risk of reintubation persisted in the high-flow oxygen group (1.5% vs 8.7%; NNT = 14; P = .001).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of high-flow oxygen therapy for 24 hours following extubation reduce the risk of reintubation in low-risk patients?

Bottom line: Using high-flow nasal cannula oxygen therapy for 24 hours following extubation of patients who are already at low risk of reintubation further reduces the risk of reintubation. You would need to treat 14 patients with high-flow therapy to prevent reintubation in one patient. (LOE = 1b)

Reference: Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA 2016;315(13):1354-1361.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis

These investigators recruited mechanically ventilated adult patients who were ready for extubation and who met the criteria for low risk for reintubation. Low risk was defined as: younger than 65 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score of less than 12; fewer than 2 comorbidities; body mass index of less than 30; ability to manage secretions; simple weaning; and the absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency issues, and prolonged mechanical ventilation.

Using concealed allocation, these patients were randomized to receive either conventional oxygen therapy or high-flow oxygen therapy for 24 hours following extubation. Conventional oxygen therapy was continued in both groups after 24 hours as needed. The 2 groups had a mean age of 51 years and similar APACHE scores at baseline. The use of high-flow oxygen therapy reduced the rate of reintubation within 72 hours from 12.2% to 4.9% (absolute difference 7.2%; 95% CI 2.5%-12.2%; number needed to treat [NNT] = 14; P = .004). There were no significant differences detected in the 2 groups in secondary outcomes including time to reintubation or hospital length of stay. Notably, the study population had a high proportion of surgical and neurocritical patients, resulting in one-third of the reintubations occurring because of nonrespiratory causes such as repeat surgery or altered mental status. When the analysis was limited to only the respiratory-related intubations, the reduced risk of reintubation persisted in the high-flow oxygen group (1.5% vs 8.7%; NNT = 14; P = .001).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of high-flow oxygen therapy for 24 hours following extubation reduce the risk of reintubation in low-risk patients?

Bottom line: Using high-flow nasal cannula oxygen therapy for 24 hours following extubation of patients who are already at low risk of reintubation further reduces the risk of reintubation. You would need to treat 14 patients with high-flow therapy to prevent reintubation in one patient. (LOE = 1b)

Reference: Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA 2016;315(13):1354-1361.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis

These investigators recruited mechanically ventilated adult patients who were ready for extubation and who met the criteria for low risk for reintubation. Low risk was defined as: younger than 65 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score of less than 12; fewer than 2 comorbidities; body mass index of less than 30; ability to manage secretions; simple weaning; and the absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency issues, and prolonged mechanical ventilation.

Using concealed allocation, these patients were randomized to receive either conventional oxygen therapy or high-flow oxygen therapy for 24 hours following extubation. Conventional oxygen therapy was continued in both groups after 24 hours as needed. The 2 groups had a mean age of 51 years and similar APACHE scores at baseline. The use of high-flow oxygen therapy reduced the rate of reintubation within 72 hours from 12.2% to 4.9% (absolute difference 7.2%; 95% CI 2.5%-12.2%; number needed to treat [NNT] = 14; P = .004). There were no significant differences detected in the 2 groups in secondary outcomes including time to reintubation or hospital length of stay. Notably, the study population had a high proportion of surgical and neurocritical patients, resulting in one-third of the reintubations occurring because of nonrespiratory causes such as repeat surgery or altered mental status. When the analysis was limited to only the respiratory-related intubations, the reduced risk of reintubation persisted in the high-flow oxygen group (1.5% vs 8.7%; NNT = 14; P = .001).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

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Offering palliative care early to hospitalized patients with multiple serious conditions could improve care and help reduce healthcare spending, according to “Palliative Care Teams’ Cost-Saving Effect Is Larger for Cancer Patients with Higher Numbers of Comorbidities,” published in Health Affairs. When adults with advanced cancer (excluding those with dementia) received a palliative care consultation within two days of admission, costs were 22% lower for patients with a comorbidity score of 2 to 3 and 32% lower for those with a score of 4 or higher.

Reference

1. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.

Quick Byte

Efforts to shift provider payment from fee-for-service to more risk-based alternatives are proceeding slowly: Nearly 95% of all 2013 physician office visits were reimbursed as fee-for-service.

Reference

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414. doi:10.1377/hlthaff.2015.1291.

Offering palliative care early to hospitalized patients with multiple serious conditions could improve care and help reduce healthcare spending, according to “Palliative Care Teams’ Cost-Saving Effect Is Larger for Cancer Patients with Higher Numbers of Comorbidities,” published in Health Affairs. When adults with advanced cancer (excluding those with dementia) received a palliative care consultation within two days of admission, costs were 22% lower for patients with a comorbidity score of 2 to 3 and 32% lower for those with a score of 4 or higher.

Reference

1. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.

Quick Byte

Efforts to shift provider payment from fee-for-service to more risk-based alternatives are proceeding slowly: Nearly 95% of all 2013 physician office visits were reimbursed as fee-for-service.

Reference

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414. doi:10.1377/hlthaff.2015.1291.

Offering palliative care early to hospitalized patients with multiple serious conditions could improve care and help reduce healthcare spending, according to “Palliative Care Teams’ Cost-Saving Effect Is Larger for Cancer Patients with Higher Numbers of Comorbidities,” published in Health Affairs. When adults with advanced cancer (excluding those with dementia) received a palliative care consultation within two days of admission, costs were 22% lower for patients with a comorbidity score of 2 to 3 and 32% lower for those with a score of 4 or higher.

Reference

1. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.

Quick Byte

Efforts to shift provider payment from fee-for-service to more risk-based alternatives are proceeding slowly: Nearly 95% of all 2013 physician office visits were reimbursed as fee-for-service.

Reference

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414. doi:10.1377/hlthaff.2015.1291.

Alert emails can be a simple, low-cost means of improving quality in a hospital, as the Department of Medicine at Massachusetts General Hospital in Boston learned. The trial there is summarized in “Alert Emails Improve Quality in a Large Academic Hospitalist Group,” an abstract by Warren Chuang, MD, and Bijay Acharya, MD.

When each of the hospital’s divisions was asked to designate important quality goals, the Hospital Medicine Division chose pre-noon discharge rate and discharge summary completion timeliness. Group emails were deployed first: Monthly alerts went to the entire unit emphasizing target numbers, reporting the group’s current performance, and outlining future performance needed to meet the targets. This led to an improvement in discharge summary completion rate from 89.1% to 94.8%.

The same improvement was not seen in the pre-noon discharge rate, so the next step was to send individual emails to every attending whose pre-noon discharge rate was below target levels. This resulted in dramatic improvement: Having fallen to 16.0%, the rate rose to 19.5% after the email campaign.

The authors’ conclusion? Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures.

Reference

1. Chuang W, Acharya B. Alert emails improve quality in a large academic hospitalist group [abstract]. J Hosp Med. 2015;10(suppl2). Available at: http://www.shmabstracts.com/abstract/alert-emails-improve-quality-in-a-large-academic-hospitalist-group/. Accessed February 14, 2016.

Alert emails can be a simple, low-cost means of improving quality in a hospital, as the Department of Medicine at Massachusetts General Hospital in Boston learned. The trial there is summarized in “Alert Emails Improve Quality in a Large Academic Hospitalist Group,” an abstract by Warren Chuang, MD, and Bijay Acharya, MD.

When each of the hospital’s divisions was asked to designate important quality goals, the Hospital Medicine Division chose pre-noon discharge rate and discharge summary completion timeliness. Group emails were deployed first: Monthly alerts went to the entire unit emphasizing target numbers, reporting the group’s current performance, and outlining future performance needed to meet the targets. This led to an improvement in discharge summary completion rate from 89.1% to 94.8%.

The same improvement was not seen in the pre-noon discharge rate, so the next step was to send individual emails to every attending whose pre-noon discharge rate was below target levels. This resulted in dramatic improvement: Having fallen to 16.0%, the rate rose to 19.5% after the email campaign.

The authors’ conclusion? Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures.

Reference

1. Chuang W, Acharya B. Alert emails improve quality in a large academic hospitalist group [abstract]. J Hosp Med. 2015;10(suppl2). Available at: http://www.shmabstracts.com/abstract/alert-emails-improve-quality-in-a-large-academic-hospitalist-group/. Accessed February 14, 2016.

Alert emails can be a simple, low-cost means of improving quality in a hospital, as the Department of Medicine at Massachusetts General Hospital in Boston learned. The trial there is summarized in “Alert Emails Improve Quality in a Large Academic Hospitalist Group,” an abstract by Warren Chuang, MD, and Bijay Acharya, MD.

When each of the hospital’s divisions was asked to designate important quality goals, the Hospital Medicine Division chose pre-noon discharge rate and discharge summary completion timeliness. Group emails were deployed first: Monthly alerts went to the entire unit emphasizing target numbers, reporting the group’s current performance, and outlining future performance needed to meet the targets. This led to an improvement in discharge summary completion rate from 89.1% to 94.8%.

The same improvement was not seen in the pre-noon discharge rate, so the next step was to send individual emails to every attending whose pre-noon discharge rate was below target levels. This resulted in dramatic improvement: Having fallen to 16.0%, the rate rose to 19.5% after the email campaign.

The authors’ conclusion? Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures.

Reference

1. Chuang W, Acharya B. Alert emails improve quality in a large academic hospitalist group [abstract]. J Hosp Med. 2015;10(suppl2). Available at: http://www.shmabstracts.com/abstract/alert-emails-improve-quality-in-a-large-academic-hospitalist-group/. Accessed February 14, 2016.