The Hospitalist

Beginning March 1 and running through December 31, all active SHM members can earn 2017–2018 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. Active members will be eligible for:

• A $35 credit toward 2017–2018 dues when recruiting 1 new member
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members

For each member recruited, individuals will receive one entry into a grand-prize drawing to receive complimentary registration to HM17 in Las Vegas.

To be counted as a referral, the new member referral must:

• Be a brand-new member to SHM (past members whose membership has lapsed do not qualify)
• Register as a physician, physician assistant, nurse practitioner, pharmacist, or affiliate member
• Include an active member’s name in the “referred by” field on a printed application or the online join form
• Join between March 1, 2016, and December 31, 2016

SHM members are not eligible for dues credits through this program for member referrals attributed to free memberships received as a result of HM17 registrations.

Begin your journey as an SHM Ambassador today at www.hospitalmedicine.org/MAP.

Beginning March 1 and running through December 31, all active SHM members can earn 2017–2018 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. Active members will be eligible for:

• A $35 credit toward 2017–2018 dues when recruiting 1 new member
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members

For each member recruited, individuals will receive one entry into a grand-prize drawing to receive complimentary registration to HM17 in Las Vegas.

To be counted as a referral, the new member referral must:

• Be a brand-new member to SHM (past members whose membership has lapsed do not qualify)
• Register as a physician, physician assistant, nurse practitioner, pharmacist, or affiliate member
• Include an active member’s name in the “referred by” field on a printed application or the online join form
• Join between March 1, 2016, and December 31, 2016

SHM members are not eligible for dues credits through this program for member referrals attributed to free memberships received as a result of HM17 registrations.

Begin your journey as an SHM Ambassador today at www.hospitalmedicine.org/MAP.

Beginning March 1 and running through December 31, all active SHM members can earn 2017–2018 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. Active members will be eligible for:

• A $35 credit toward 2017–2018 dues when recruiting 1 new member
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members

For each member recruited, individuals will receive one entry into a grand-prize drawing to receive complimentary registration to HM17 in Las Vegas.

To be counted as a referral, the new member referral must:

• Be a brand-new member to SHM (past members whose membership has lapsed do not qualify)
• Register as a physician, physician assistant, nurse practitioner, pharmacist, or affiliate member
• Include an active member’s name in the “referred by” field on a printed application or the online join form
• Join between March 1, 2016, and December 31, 2016

SHM members are not eligible for dues credits through this program for member referrals attributed to free memberships received as a result of HM17 registrations.

Begin your journey as an SHM Ambassador today at www.hospitalmedicine.org/MAP.

NEW YORK (Reuters Health) - Receiving the seasonal flu vaccine while in the hospital does not increase surgical patients' health care utilization or their likelihood of being evaluated for infection after discharge, according to a new retrospective cohort study.

The Advisory Committee on Immunization Practices recommends that hospitalized patients who are eligible for the flu vaccine receive it before discharge, but rates of vaccination remain low in surgical patients, Dr. Sara Tartof of Kaiser Permanente Southern California in Pasadena and her colleagues note in their report, published online March 14 in the Annals of Internal Medicine.

This could be due to surgeons' concerns that adverse effects of influenza vaccine such as myalgia or fever could be attributed to surgical complications, or could complicate post-surgical care, they add.

"When we searched in the literature, we really just couldn't find any data that really speak to this question," Dr. Tartof told Reuters Health in a telephone interview.

She and her colleagues looked at Kaiser Permanente Southern California patients aged six months or older who had inpatient surgery between September 2010 and March 2013. Of the 42,777 surgeries in their analysis, 6,420 included seasonal flu vaccination during hospitalization.

The researchers found no differences between the vaccinated and unvaccinated groups in the risk of inpatient visits,emergency department visits, post-discharge fever, or clinical evaluation for infection. There was a marginal increase in the risk of outpatient visits (relative risk 1.05, p=0.032).

"We feel that the benefits of vaccination outweigh this risk," Dr. Tartof said. "For high-risk patients, this is a health care contact, this is an opportunity to vaccinate, and we don't want to miss those."

Many patients in the study who were vaccinated against the flu received the shot when they were discharged, the researcher noted. "This may be a more comfortable time for patients and for their clinicians to vaccinate," she said.

Dr. Tartof and her colleagues are now planning to repeat the study in a larger population of nonsurgical inpatients, including children.

The Centers for Disease Control and Prevention funded this research. Five coauthors reported disclosures.

 

 

 

 

 

NEW YORK (Reuters Health) - Receiving the seasonal flu vaccine while in the hospital does not increase surgical patients' health care utilization or their likelihood of being evaluated for infection after discharge, according to a new retrospective cohort study.

The Advisory Committee on Immunization Practices recommends that hospitalized patients who are eligible for the flu vaccine receive it before discharge, but rates of vaccination remain low in surgical patients, Dr. Sara Tartof of Kaiser Permanente Southern California in Pasadena and her colleagues note in their report, published online March 14 in the Annals of Internal Medicine.

This could be due to surgeons' concerns that adverse effects of influenza vaccine such as myalgia or fever could be attributed to surgical complications, or could complicate post-surgical care, they add.

"When we searched in the literature, we really just couldn't find any data that really speak to this question," Dr. Tartof told Reuters Health in a telephone interview.

She and her colleagues looked at Kaiser Permanente Southern California patients aged six months or older who had inpatient surgery between September 2010 and March 2013. Of the 42,777 surgeries in their analysis, 6,420 included seasonal flu vaccination during hospitalization.

The researchers found no differences between the vaccinated and unvaccinated groups in the risk of inpatient visits,emergency department visits, post-discharge fever, or clinical evaluation for infection. There was a marginal increase in the risk of outpatient visits (relative risk 1.05, p=0.032).

"We feel that the benefits of vaccination outweigh this risk," Dr. Tartof said. "For high-risk patients, this is a health care contact, this is an opportunity to vaccinate, and we don't want to miss those."

Many patients in the study who were vaccinated against the flu received the shot when they were discharged, the researcher noted. "This may be a more comfortable time for patients and for their clinicians to vaccinate," she said.

Dr. Tartof and her colleagues are now planning to repeat the study in a larger population of nonsurgical inpatients, including children.

The Centers for Disease Control and Prevention funded this research. Five coauthors reported disclosures.

 

 

 

 

 

NEW YORK (Reuters Health) - Receiving the seasonal flu vaccine while in the hospital does not increase surgical patients' health care utilization or their likelihood of being evaluated for infection after discharge, according to a new retrospective cohort study.

The Advisory Committee on Immunization Practices recommends that hospitalized patients who are eligible for the flu vaccine receive it before discharge, but rates of vaccination remain low in surgical patients, Dr. Sara Tartof of Kaiser Permanente Southern California in Pasadena and her colleagues note in their report, published online March 14 in the Annals of Internal Medicine.

This could be due to surgeons' concerns that adverse effects of influenza vaccine such as myalgia or fever could be attributed to surgical complications, or could complicate post-surgical care, they add.

"When we searched in the literature, we really just couldn't find any data that really speak to this question," Dr. Tartof told Reuters Health in a telephone interview.

She and her colleagues looked at Kaiser Permanente Southern California patients aged six months or older who had inpatient surgery between September 2010 and March 2013. Of the 42,777 surgeries in their analysis, 6,420 included seasonal flu vaccination during hospitalization.

The researchers found no differences between the vaccinated and unvaccinated groups in the risk of inpatient visits,emergency department visits, post-discharge fever, or clinical evaluation for infection. There was a marginal increase in the risk of outpatient visits (relative risk 1.05, p=0.032).

"We feel that the benefits of vaccination outweigh this risk," Dr. Tartof said. "For high-risk patients, this is a health care contact, this is an opportunity to vaccinate, and we don't want to miss those."

Many patients in the study who were vaccinated against the flu received the shot when they were discharged, the researcher noted. "This may be a more comfortable time for patients and for their clinicians to vaccinate," she said.

Dr. Tartof and her colleagues are now planning to repeat the study in a larger population of nonsurgical inpatients, including children.

The Centers for Disease Control and Prevention funded this research. Five coauthors reported disclosures.

 

 

 

 

 

In 1955, there was one psychiatric bed for every 300 Americans. By 2005, following the widespread shuttering or downsizing of psychiatric hospitals in the 1990s, that number had shrunk to one bed for every 3,000 Americans.1

In 2008, an estimated 39.8 million Americans age 18 or older had mental illness, which represents 17.7% of U.S. adults.2 In 2013, this number rose to an estimated 43.8 million, or 18.5% of U.S. adults (see Figure 1).3

“It’s like we have returned to the early 19th century, when mentally ill persons were held in prisons or temporarily kept in hospital settings,” says Ricardo Bianco, PsyD, program director of the Master of Arts in counseling and health psychology at William James College in Newton, Mass. “The problem is that the healthcare system did not catch up to absorb the mentally ill population.

“As a result, hospital staffs are inadequately trained, there is insufficient funding for these patients, and there are not enough human resource personnel to manage them. Consequently, hospitalists are overwhelmed with cases that should be primarily treated by psychologists, psychiatrists, and social workers.”

According to David M. Grace, MD, SFHM, hospitalist and senior medical officer at the Schumacher Group in Lafayette, La., two groups of psychiatric patients present to the acute-care hospital environment: those who are there for a primary psychiatric problem and those who have a medical problem and a psychiatric comorbidity. The first group of patients presents distinct challenges. U.S. hospitals lack two-thirds of the minimum number of beds needed to care for this population. The second group is problematic because psychiatric issues often cloud the medical issues of a patient, increasing both diagnostic uncertainty and resource utilization.

Challenges Abound

Psychiatric patients present a number of problems for hospitalists. First, it is difficult to decipher what comprises a psychiatric issue and what does not because “many psychiatric conditions manifest as physical symptoms and they often require significant resource consumption to diagnose,” Dr. Grace says. Secondly, some patients present with a severe primary psychiatric problem in which they are homicidal, suicidal, or gravely disabled.

In addition, psychiatric patients tend to have a greater incidence of noncompliance with imaging, laboratory work, medication, and general medical care, says Daniel Sussman, MD, a hospitalist at IPC Healthcare, Inc., based in North Hollywood, Calif. He also serves as interim chairman in the department of psychiatry at St. John’s Episcopal Hospital in Far Rockaway, N.Y.

Clinically, potential interactions between psychiatric medications and medically related prescription drugs are always a concern, notes Dr. Sussman, who says more than 70% of patients admitted to St. John’s Episcopal Hospital have a major psychiatric illness in addition to their medical problem. Psychiatric medications, which patients may have tolerated well when they were stable, may be too sedating when patients are ill. Side effects and adverse reactions of psychotropic medications must also be considered when diagnosing and treating medical illnesses. Metabolic syndrome is more commonly seen and is a factor in the development and subsequent treatment of other illnesses.

Another challenge stems from the fact that patients with substantial psychiatric comorbidities can have significant and rapid mood and behavioral changes as well as sudden, volatile, and aggressive outbursts—both verbal and physical.

“Staff members who interact with the patient are at risk if an outburst occurs,” says Emily Fingado, MD, FAAP, a pediatric hospitalist and clinical assistant professor of pediatrics at Nemours/Alfred I. duPont Hospital for Children (Nemours/AIDHC) of the Sidney Kimmel Medical College at Thomas Jefferson University in Wilmington, Del.

 

Such situations can become scary, particularly if someone with psychiatric expertise is not available to intervene. This can be very frustrating for hospitalists who want to provide high-level care but may lack the training needed to be successful with such patients. This can ultimately lead to burnout, says Sarah Rivelli, MD, medical director of psychiatry clinical services at Duke University Hospital and Duke University Medical Center in Durham, N.C.

Another challenge is that although there are protocols in place designed to follow specific steps for patients with physical illnesses or disorders, that’s not the case for psychiatric illness. “Many hospital facilities are not designed, or have yet to implement, protocols to attend to mentally ill individuals,” Dr. Bianco says.

Because of the unpredictability of patients and lack of practice protocols, mental illness can introduce a wild card into the standard treatment process. A more individualized approach with these patients is needed, but with increasing focus on length of stay and operational efficiency, medical and nursing staffs are pressured to do things quickly and to do more with less. It can be very time-consuming for a nurse to have to explain to paranoid patients why they should take their medication or for a phlebotomist to try to calm patients in order to obtain blood. When patients refuse needed tests, or only provide a limited history, the hospitalist ends up working with incomplete information, which makes choosing and monitoring the treatment approach problematic.

A Look at Best Practices

In light of challenges, some best practices have been identified for handling psychiatric patients. As previously mentioned, most hospital staffs have limited formal training in interacting with psychiatric patients. In fact, the American Board of Internal Medicine only devotes 4% of the certification exam to psychiatry.4

Ideally, staff members who care for psychiatric patients will have specialized or additional training in managing patients with psychiatric conditions or comorbidities. Nemours/AIDHC has a committee assigned to evaluate psychiatric patients’ care and help manage them when a behavioral emergency occurs, Dr. Fingado says. This team, which has been trained on de-escalation, restraint techniques and policies, as well as medications to use in these situations, intervenes when patients have an aggressive event that places patients, visitors, or staff at risk. The team includes nursing staff, the hospitalist on-call, and security personnel and involves the social work, psychology, and psychiatry departments.

Training focused on treating patients with psychiatric conditions should include how to recognize substance abuse and treat substance withdrawal because mental illness and substance abuse often track together, Dr. Sussman notes. At St. John’s Episcopal Hospital, patients with chronic mental illness are not the ones who typically become aggressive or violent. Rather, this is more often the case among patients with substance abuse either in states of acute intoxication or withdrawal.

Recently, Dr. Sussman has seen a significant increase in patients who abuse K2, or spice, a synthetic form of cannabis. Side effects of using K2 include rapid heart rate, anxiety, hallucinations, and paranoia to the point of delusional thinking. These side effects can frequently wax and wane for days after the drug is used, and they can be associated with significant psychomotor agitation and assaultive behavior.

When patients abuse flake, another synthetic drug that has been reported in the Southeast, they tend to become very paranoid and violent. “These patients can be extremely unpredictable and aggressive,” he says. “Patients with dementia can be impulsive and aggressive during care, and caution is needed, but it’s not a directed violence like that seen in patients who are agitated secondary to substance abuse.”

 

Dr. Bianco advises having a predetermined triage system or a scale that can assess and measure patients’ level of psychological distress, which can ensure timely and appropriate evaluation and treatment of psychiatric patients, as well as toxicology screens and mental health protocols, which can aid in diagnosis.

“Technology is an important tool in facilitating integration, including identifying and screening patients, tracking patient progress, encouraging adherence to clinical protocols, facilitating communication between providers, and evaluating the impact of integrated programs,” Dr. Bianco says. Academic hospitals struggle less with this problem, he adds, because they tend to be more adequately funded in all areas of operations, including the field of mental health.

IPC Healthcare hospitalist James N. Horst, DO, a psychiatrist who manages mental health patients in a long-term care and nursing home facility, says he has found standardized general screening tools to be useful. The Hamilton Depression Scale, Beck Anxiety Inventory, and CAGE exam for chemical dependency can be easily administered and scored in any facility setting, he says. These tests include self-administered questions to which the patient answers yes or no. Laboratory work is a secondary tool in psychiatry since few mental illness disorders are based on medical comorbidities.

Dr. Sussman looks to the past, when psychiatrists were part of medical teams rounding in hospitals, for a solution. “An integrated model provides an approach where patient care is less compartmentalized,” he says. “In this model, clinicians are responsible for making sure their patient is treated, not simply focusing on their individual area of expertise. This involves working more closely with an integrated care management team.”

Ideally, this will occur at every level of care: outpatient, inpatient, and emergency department (ED). New York State is attempting to redesign the Medicaid system in this fashion, with the goal of improving overall care and reducing reliance on inpatient treatment to provide that care. This is an enormous initiative, costing more than $8 billion. If successful, it will result in a more patient-centered care system that treats the whole individual, not just the illness, and will positively impact patients’ overall health.

For now, St. John’s Episcopal Hospital has an active psychiatric consultation liaison service that is staffed by both in-house residents and attending physicians who are there 24-7 to help with psychiatric patients.

A ‘Utopia Management’ Perspective

In a dream world, patients with significant psychiatric problems or comorbidities would have coordinated, multidisciplinary care from admission to discharge, Dr. Fingado adds. Ideally, hospitals would have dedicated rooms or areas in the ED that are safe for patients and staff. Psychiatric patients who require observation or admission to a non-psychiatric hospital would be placed in rooms or units dedicated for psychiatric patients, again providing safety for patients and staff, Dr. Fingado surmises.

In addition, all staff members would have training in behavioral health management, including instruction on de-escalation, restraint techniques, and medication use for patients. Ideally, units would be staffed by specially trained aides, nurses, and healthcare providers (i.e., physician assistants, nurse practitioners, physicians), as well as psychologists and psychiatrists, Dr. Fingado says. This type of management would require buy-in from a multitude of groups, including healthcare administrators, nursing and provider staff, as well as health insurance companies. A reallocation or increase in funds would be needed to help build and staff these types of management models and locations, she adds.

In a perfect world, all hospitalized patients would be adequately screened for mental health issues and have their issues appropriately addressed by well-qualified professionals in real time, Dr. Grace says. Telemedicine services have great potential in helping to meet that goal, he says, and more relaxed regulatory guidelines around telemedicine could help make such physician-patient interactions less difficult. Many, if not most, hospitals currently have limited or no access to qualified mental health professionals, a conundrum based on supply, reimbursement, and need.

 

“Telemedicine, which is already having great success in neurology and intensive care unit medicine, is a great fit for this space,” Dr. Grace says. “Widespread access to a tele-psychiatrist would bring significant tangible benefits to patients, hospitals, hospital staff, and the population at large, who ultimately pay for healthcare in the nation.”

Dr. Horst says he believes everyone who treats psychiatric patients should have education in psychiatric medicine education. One way to achieve this would be to mandate continuing medical education coursework in mental health disorders.

The Reality of a Utopia

Traditionally, our healthcare system has been designed to react to illness, meaning that physicians treat illnesses when individuals become sick.

“But as science and technology now better understand the etiology of most illnesses, we are more equipped to design more preventative interventions rather than wait for individuals to become sick,” Dr. Bianco says. “Prevention interventions require an initial investment that the healthcare system is not necessarily willing to invest in at this time and a shift in the way it charges for services. If the healthcare system is unwilling to go that route, and we know we can prevent many illnesses by shifting the focus of treatment, consequently, human suffering is augmented and quality of life jeopardized.”

More recently, the general population and providers have acknowledged that healing takes place more effectively when it is applied in more integrated approaches (i.e., the utilization of the bio-psycho-social-spiritual model), Dr. Bianco adds. This greater appreciation is demonstrated by different research studies applied to different populations (both the general public and different providers). Despite this, the system (i.e., training) does not support a full integration of interventions.

“The system continues to operate under the traditional medical model that is fragmented and hyper-specialized,” Dr. Bianco says. “Science has demonstrated that the mind and the body work in more complex ways, requiring a more holistic approach to treatment. Although all segments among providers now understand and accept that, the system they dwell in does not support the daily challenges of treatment.

“Treatment continues to be fragmented as it is the medical model. At this point, at a minimum, a hospital should have a psychiatric department composed of individuals who are adequately trained (e.g., health psychology, behavioral medicine) to absorb a portion of individuals who primarily present with mental health issues.” TH

---

Karen Appold is a freelance medical writer in Pennsylvania.

References

1. Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Treatment Advocacy Center website. Available at: http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf. May 2010. Accessed August 18, 2015.
2. Results from the 2013 national survey on drug use and health: mental health detailed tables. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, U.S. Department of Health & Human Services website. Available at: http://www.samhsa.gov/data/sites/default/files/2013MHDetTabs/NSDUH-MHDetTabs2013.pdf. Accessed August 19, 2015.
3. Any mental illness among adults. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-adults.shtml. Accessed August 19, 2015.
4. Internal medicine certification examination blueprint. American Board of Internal Medicine website. Available at: https://www.abim.org/pdf/blueprint/im_cert.pdf. January 2015. Accessed August 19, 2015.

 

In 1955, there was one psychiatric bed for every 300 Americans. By 2005, following the widespread shuttering or downsizing of psychiatric hospitals in the 1990s, that number had shrunk to one bed for every 3,000 Americans.1

In 2008, an estimated 39.8 million Americans age 18 or older had mental illness, which represents 17.7% of U.S. adults.2 In 2013, this number rose to an estimated 43.8 million, or 18.5% of U.S. adults (see Figure 1).3

“It’s like we have returned to the early 19th century, when mentally ill persons were held in prisons or temporarily kept in hospital settings,” says Ricardo Bianco, PsyD, program director of the Master of Arts in counseling and health psychology at William James College in Newton, Mass. “The problem is that the healthcare system did not catch up to absorb the mentally ill population.

“As a result, hospital staffs are inadequately trained, there is insufficient funding for these patients, and there are not enough human resource personnel to manage them. Consequently, hospitalists are overwhelmed with cases that should be primarily treated by psychologists, psychiatrists, and social workers.”

According to David M. Grace, MD, SFHM, hospitalist and senior medical officer at the Schumacher Group in Lafayette, La., two groups of psychiatric patients present to the acute-care hospital environment: those who are there for a primary psychiatric problem and those who have a medical problem and a psychiatric comorbidity. The first group of patients presents distinct challenges. U.S. hospitals lack two-thirds of the minimum number of beds needed to care for this population. The second group is problematic because psychiatric issues often cloud the medical issues of a patient, increasing both diagnostic uncertainty and resource utilization.

Challenges Abound

Psychiatric patients present a number of problems for hospitalists. First, it is difficult to decipher what comprises a psychiatric issue and what does not because “many psychiatric conditions manifest as physical symptoms and they often require significant resource consumption to diagnose,” Dr. Grace says. Secondly, some patients present with a severe primary psychiatric problem in which they are homicidal, suicidal, or gravely disabled.

In addition, psychiatric patients tend to have a greater incidence of noncompliance with imaging, laboratory work, medication, and general medical care, says Daniel Sussman, MD, a hospitalist at IPC Healthcare, Inc., based in North Hollywood, Calif. He also serves as interim chairman in the department of psychiatry at St. John’s Episcopal Hospital in Far Rockaway, N.Y.

Clinically, potential interactions between psychiatric medications and medically related prescription drugs are always a concern, notes Dr. Sussman, who says more than 70% of patients admitted to St. John’s Episcopal Hospital have a major psychiatric illness in addition to their medical problem. Psychiatric medications, which patients may have tolerated well when they were stable, may be too sedating when patients are ill. Side effects and adverse reactions of psychotropic medications must also be considered when diagnosing and treating medical illnesses. Metabolic syndrome is more commonly seen and is a factor in the development and subsequent treatment of other illnesses.

Another challenge stems from the fact that patients with substantial psychiatric comorbidities can have significant and rapid mood and behavioral changes as well as sudden, volatile, and aggressive outbursts—both verbal and physical.

“Staff members who interact with the patient are at risk if an outburst occurs,” says Emily Fingado, MD, FAAP, a pediatric hospitalist and clinical assistant professor of pediatrics at Nemours/Alfred I. duPont Hospital for Children (Nemours/AIDHC) of the Sidney Kimmel Medical College at Thomas Jefferson University in Wilmington, Del.

 

Such situations can become scary, particularly if someone with psychiatric expertise is not available to intervene. This can be very frustrating for hospitalists who want to provide high-level care but may lack the training needed to be successful with such patients. This can ultimately lead to burnout, says Sarah Rivelli, MD, medical director of psychiatry clinical services at Duke University Hospital and Duke University Medical Center in Durham, N.C.

Another challenge is that although there are protocols in place designed to follow specific steps for patients with physical illnesses or disorders, that’s not the case for psychiatric illness. “Many hospital facilities are not designed, or have yet to implement, protocols to attend to mentally ill individuals,” Dr. Bianco says.

Because of the unpredictability of patients and lack of practice protocols, mental illness can introduce a wild card into the standard treatment process. A more individualized approach with these patients is needed, but with increasing focus on length of stay and operational efficiency, medical and nursing staffs are pressured to do things quickly and to do more with less. It can be very time-consuming for a nurse to have to explain to paranoid patients why they should take their medication or for a phlebotomist to try to calm patients in order to obtain blood. When patients refuse needed tests, or only provide a limited history, the hospitalist ends up working with incomplete information, which makes choosing and monitoring the treatment approach problematic.

A Look at Best Practices

In light of challenges, some best practices have been identified for handling psychiatric patients. As previously mentioned, most hospital staffs have limited formal training in interacting with psychiatric patients. In fact, the American Board of Internal Medicine only devotes 4% of the certification exam to psychiatry.4

Ideally, staff members who care for psychiatric patients will have specialized or additional training in managing patients with psychiatric conditions or comorbidities. Nemours/AIDHC has a committee assigned to evaluate psychiatric patients’ care and help manage them when a behavioral emergency occurs, Dr. Fingado says. This team, which has been trained on de-escalation, restraint techniques and policies, as well as medications to use in these situations, intervenes when patients have an aggressive event that places patients, visitors, or staff at risk. The team includes nursing staff, the hospitalist on-call, and security personnel and involves the social work, psychology, and psychiatry departments.

Training focused on treating patients with psychiatric conditions should include how to recognize substance abuse and treat substance withdrawal because mental illness and substance abuse often track together, Dr. Sussman notes. At St. John’s Episcopal Hospital, patients with chronic mental illness are not the ones who typically become aggressive or violent. Rather, this is more often the case among patients with substance abuse either in states of acute intoxication or withdrawal.

Recently, Dr. Sussman has seen a significant increase in patients who abuse K2, or spice, a synthetic form of cannabis. Side effects of using K2 include rapid heart rate, anxiety, hallucinations, and paranoia to the point of delusional thinking. These side effects can frequently wax and wane for days after the drug is used, and they can be associated with significant psychomotor agitation and assaultive behavior.

When patients abuse flake, another synthetic drug that has been reported in the Southeast, they tend to become very paranoid and violent. “These patients can be extremely unpredictable and aggressive,” he says. “Patients with dementia can be impulsive and aggressive during care, and caution is needed, but it’s not a directed violence like that seen in patients who are agitated secondary to substance abuse.”

 

Dr. Bianco advises having a predetermined triage system or a scale that can assess and measure patients’ level of psychological distress, which can ensure timely and appropriate evaluation and treatment of psychiatric patients, as well as toxicology screens and mental health protocols, which can aid in diagnosis.

“Technology is an important tool in facilitating integration, including identifying and screening patients, tracking patient progress, encouraging adherence to clinical protocols, facilitating communication between providers, and evaluating the impact of integrated programs,” Dr. Bianco says. Academic hospitals struggle less with this problem, he adds, because they tend to be more adequately funded in all areas of operations, including the field of mental health.

IPC Healthcare hospitalist James N. Horst, DO, a psychiatrist who manages mental health patients in a long-term care and nursing home facility, says he has found standardized general screening tools to be useful. The Hamilton Depression Scale, Beck Anxiety Inventory, and CAGE exam for chemical dependency can be easily administered and scored in any facility setting, he says. These tests include self-administered questions to which the patient answers yes or no. Laboratory work is a secondary tool in psychiatry since few mental illness disorders are based on medical comorbidities.

Dr. Sussman looks to the past, when psychiatrists were part of medical teams rounding in hospitals, for a solution. “An integrated model provides an approach where patient care is less compartmentalized,” he says. “In this model, clinicians are responsible for making sure their patient is treated, not simply focusing on their individual area of expertise. This involves working more closely with an integrated care management team.”

Ideally, this will occur at every level of care: outpatient, inpatient, and emergency department (ED). New York State is attempting to redesign the Medicaid system in this fashion, with the goal of improving overall care and reducing reliance on inpatient treatment to provide that care. This is an enormous initiative, costing more than $8 billion. If successful, it will result in a more patient-centered care system that treats the whole individual, not just the illness, and will positively impact patients’ overall health.

For now, St. John’s Episcopal Hospital has an active psychiatric consultation liaison service that is staffed by both in-house residents and attending physicians who are there 24-7 to help with psychiatric patients.

A ‘Utopia Management’ Perspective

In a dream world, patients with significant psychiatric problems or comorbidities would have coordinated, multidisciplinary care from admission to discharge, Dr. Fingado adds. Ideally, hospitals would have dedicated rooms or areas in the ED that are safe for patients and staff. Psychiatric patients who require observation or admission to a non-psychiatric hospital would be placed in rooms or units dedicated for psychiatric patients, again providing safety for patients and staff, Dr. Fingado surmises.

In addition, all staff members would have training in behavioral health management, including instruction on de-escalation, restraint techniques, and medication use for patients. Ideally, units would be staffed by specially trained aides, nurses, and healthcare providers (i.e., physician assistants, nurse practitioners, physicians), as well as psychologists and psychiatrists, Dr. Fingado says. This type of management would require buy-in from a multitude of groups, including healthcare administrators, nursing and provider staff, as well as health insurance companies. A reallocation or increase in funds would be needed to help build and staff these types of management models and locations, she adds.

In a perfect world, all hospitalized patients would be adequately screened for mental health issues and have their issues appropriately addressed by well-qualified professionals in real time, Dr. Grace says. Telemedicine services have great potential in helping to meet that goal, he says, and more relaxed regulatory guidelines around telemedicine could help make such physician-patient interactions less difficult. Many, if not most, hospitals currently have limited or no access to qualified mental health professionals, a conundrum based on supply, reimbursement, and need.

 

“Telemedicine, which is already having great success in neurology and intensive care unit medicine, is a great fit for this space,” Dr. Grace says. “Widespread access to a tele-psychiatrist would bring significant tangible benefits to patients, hospitals, hospital staff, and the population at large, who ultimately pay for healthcare in the nation.”

Dr. Horst says he believes everyone who treats psychiatric patients should have education in psychiatric medicine education. One way to achieve this would be to mandate continuing medical education coursework in mental health disorders.

The Reality of a Utopia

Traditionally, our healthcare system has been designed to react to illness, meaning that physicians treat illnesses when individuals become sick.

“But as science and technology now better understand the etiology of most illnesses, we are more equipped to design more preventative interventions rather than wait for individuals to become sick,” Dr. Bianco says. “Prevention interventions require an initial investment that the healthcare system is not necessarily willing to invest in at this time and a shift in the way it charges for services. If the healthcare system is unwilling to go that route, and we know we can prevent many illnesses by shifting the focus of treatment, consequently, human suffering is augmented and quality of life jeopardized.”

More recently, the general population and providers have acknowledged that healing takes place more effectively when it is applied in more integrated approaches (i.e., the utilization of the bio-psycho-social-spiritual model), Dr. Bianco adds. This greater appreciation is demonstrated by different research studies applied to different populations (both the general public and different providers). Despite this, the system (i.e., training) does not support a full integration of interventions.

“The system continues to operate under the traditional medical model that is fragmented and hyper-specialized,” Dr. Bianco says. “Science has demonstrated that the mind and the body work in more complex ways, requiring a more holistic approach to treatment. Although all segments among providers now understand and accept that, the system they dwell in does not support the daily challenges of treatment.

“Treatment continues to be fragmented as it is the medical model. At this point, at a minimum, a hospital should have a psychiatric department composed of individuals who are adequately trained (e.g., health psychology, behavioral medicine) to absorb a portion of individuals who primarily present with mental health issues.” TH

---

Karen Appold is a freelance medical writer in Pennsylvania.

References

1. Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Treatment Advocacy Center website. Available at: http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf. May 2010. Accessed August 18, 2015.
2. Results from the 2013 national survey on drug use and health: mental health detailed tables. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, U.S. Department of Health & Human Services website. Available at: http://www.samhsa.gov/data/sites/default/files/2013MHDetTabs/NSDUH-MHDetTabs2013.pdf. Accessed August 19, 2015.
3. Any mental illness among adults. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-adults.shtml. Accessed August 19, 2015.
4. Internal medicine certification examination blueprint. American Board of Internal Medicine website. Available at: https://www.abim.org/pdf/blueprint/im_cert.pdf. January 2015. Accessed August 19, 2015.

 

In 1955, there was one psychiatric bed for every 300 Americans. By 2005, following the widespread shuttering or downsizing of psychiatric hospitals in the 1990s, that number had shrunk to one bed for every 3,000 Americans.1

In 2008, an estimated 39.8 million Americans age 18 or older had mental illness, which represents 17.7% of U.S. adults.2 In 2013, this number rose to an estimated 43.8 million, or 18.5% of U.S. adults (see Figure 1).3

“It’s like we have returned to the early 19th century, when mentally ill persons were held in prisons or temporarily kept in hospital settings,” says Ricardo Bianco, PsyD, program director of the Master of Arts in counseling and health psychology at William James College in Newton, Mass. “The problem is that the healthcare system did not catch up to absorb the mentally ill population.

“As a result, hospital staffs are inadequately trained, there is insufficient funding for these patients, and there are not enough human resource personnel to manage them. Consequently, hospitalists are overwhelmed with cases that should be primarily treated by psychologists, psychiatrists, and social workers.”

According to David M. Grace, MD, SFHM, hospitalist and senior medical officer at the Schumacher Group in Lafayette, La., two groups of psychiatric patients present to the acute-care hospital environment: those who are there for a primary psychiatric problem and those who have a medical problem and a psychiatric comorbidity. The first group of patients presents distinct challenges. U.S. hospitals lack two-thirds of the minimum number of beds needed to care for this population. The second group is problematic because psychiatric issues often cloud the medical issues of a patient, increasing both diagnostic uncertainty and resource utilization.

Challenges Abound

Psychiatric patients present a number of problems for hospitalists. First, it is difficult to decipher what comprises a psychiatric issue and what does not because “many psychiatric conditions manifest as physical symptoms and they often require significant resource consumption to diagnose,” Dr. Grace says. Secondly, some patients present with a severe primary psychiatric problem in which they are homicidal, suicidal, or gravely disabled.

In addition, psychiatric patients tend to have a greater incidence of noncompliance with imaging, laboratory work, medication, and general medical care, says Daniel Sussman, MD, a hospitalist at IPC Healthcare, Inc., based in North Hollywood, Calif. He also serves as interim chairman in the department of psychiatry at St. John’s Episcopal Hospital in Far Rockaway, N.Y.

Clinically, potential interactions between psychiatric medications and medically related prescription drugs are always a concern, notes Dr. Sussman, who says more than 70% of patients admitted to St. John’s Episcopal Hospital have a major psychiatric illness in addition to their medical problem. Psychiatric medications, which patients may have tolerated well when they were stable, may be too sedating when patients are ill. Side effects and adverse reactions of psychotropic medications must also be considered when diagnosing and treating medical illnesses. Metabolic syndrome is more commonly seen and is a factor in the development and subsequent treatment of other illnesses.

Another challenge stems from the fact that patients with substantial psychiatric comorbidities can have significant and rapid mood and behavioral changes as well as sudden, volatile, and aggressive outbursts—both verbal and physical.

“Staff members who interact with the patient are at risk if an outburst occurs,” says Emily Fingado, MD, FAAP, a pediatric hospitalist and clinical assistant professor of pediatrics at Nemours/Alfred I. duPont Hospital for Children (Nemours/AIDHC) of the Sidney Kimmel Medical College at Thomas Jefferson University in Wilmington, Del.

 

Such situations can become scary, particularly if someone with psychiatric expertise is not available to intervene. This can be very frustrating for hospitalists who want to provide high-level care but may lack the training needed to be successful with such patients. This can ultimately lead to burnout, says Sarah Rivelli, MD, medical director of psychiatry clinical services at Duke University Hospital and Duke University Medical Center in Durham, N.C.

Another challenge is that although there are protocols in place designed to follow specific steps for patients with physical illnesses or disorders, that’s not the case for psychiatric illness. “Many hospital facilities are not designed, or have yet to implement, protocols to attend to mentally ill individuals,” Dr. Bianco says.

Because of the unpredictability of patients and lack of practice protocols, mental illness can introduce a wild card into the standard treatment process. A more individualized approach with these patients is needed, but with increasing focus on length of stay and operational efficiency, medical and nursing staffs are pressured to do things quickly and to do more with less. It can be very time-consuming for a nurse to have to explain to paranoid patients why they should take their medication or for a phlebotomist to try to calm patients in order to obtain blood. When patients refuse needed tests, or only provide a limited history, the hospitalist ends up working with incomplete information, which makes choosing and monitoring the treatment approach problematic.

A Look at Best Practices

In light of challenges, some best practices have been identified for handling psychiatric patients. As previously mentioned, most hospital staffs have limited formal training in interacting with psychiatric patients. In fact, the American Board of Internal Medicine only devotes 4% of the certification exam to psychiatry.4

Ideally, staff members who care for psychiatric patients will have specialized or additional training in managing patients with psychiatric conditions or comorbidities. Nemours/AIDHC has a committee assigned to evaluate psychiatric patients’ care and help manage them when a behavioral emergency occurs, Dr. Fingado says. This team, which has been trained on de-escalation, restraint techniques and policies, as well as medications to use in these situations, intervenes when patients have an aggressive event that places patients, visitors, or staff at risk. The team includes nursing staff, the hospitalist on-call, and security personnel and involves the social work, psychology, and psychiatry departments.

Training focused on treating patients with psychiatric conditions should include how to recognize substance abuse and treat substance withdrawal because mental illness and substance abuse often track together, Dr. Sussman notes. At St. John’s Episcopal Hospital, patients with chronic mental illness are not the ones who typically become aggressive or violent. Rather, this is more often the case among patients with substance abuse either in states of acute intoxication or withdrawal.

Recently, Dr. Sussman has seen a significant increase in patients who abuse K2, or spice, a synthetic form of cannabis. Side effects of using K2 include rapid heart rate, anxiety, hallucinations, and paranoia to the point of delusional thinking. These side effects can frequently wax and wane for days after the drug is used, and they can be associated with significant psychomotor agitation and assaultive behavior.

When patients abuse flake, another synthetic drug that has been reported in the Southeast, they tend to become very paranoid and violent. “These patients can be extremely unpredictable and aggressive,” he says. “Patients with dementia can be impulsive and aggressive during care, and caution is needed, but it’s not a directed violence like that seen in patients who are agitated secondary to substance abuse.”

 

Dr. Bianco advises having a predetermined triage system or a scale that can assess and measure patients’ level of psychological distress, which can ensure timely and appropriate evaluation and treatment of psychiatric patients, as well as toxicology screens and mental health protocols, which can aid in diagnosis.

“Technology is an important tool in facilitating integration, including identifying and screening patients, tracking patient progress, encouraging adherence to clinical protocols, facilitating communication between providers, and evaluating the impact of integrated programs,” Dr. Bianco says. Academic hospitals struggle less with this problem, he adds, because they tend to be more adequately funded in all areas of operations, including the field of mental health.

IPC Healthcare hospitalist James N. Horst, DO, a psychiatrist who manages mental health patients in a long-term care and nursing home facility, says he has found standardized general screening tools to be useful. The Hamilton Depression Scale, Beck Anxiety Inventory, and CAGE exam for chemical dependency can be easily administered and scored in any facility setting, he says. These tests include self-administered questions to which the patient answers yes or no. Laboratory work is a secondary tool in psychiatry since few mental illness disorders are based on medical comorbidities.

Dr. Sussman looks to the past, when psychiatrists were part of medical teams rounding in hospitals, for a solution. “An integrated model provides an approach where patient care is less compartmentalized,” he says. “In this model, clinicians are responsible for making sure their patient is treated, not simply focusing on their individual area of expertise. This involves working more closely with an integrated care management team.”

Ideally, this will occur at every level of care: outpatient, inpatient, and emergency department (ED). New York State is attempting to redesign the Medicaid system in this fashion, with the goal of improving overall care and reducing reliance on inpatient treatment to provide that care. This is an enormous initiative, costing more than $8 billion. If successful, it will result in a more patient-centered care system that treats the whole individual, not just the illness, and will positively impact patients’ overall health.

For now, St. John’s Episcopal Hospital has an active psychiatric consultation liaison service that is staffed by both in-house residents and attending physicians who are there 24-7 to help with psychiatric patients.

A ‘Utopia Management’ Perspective

In a dream world, patients with significant psychiatric problems or comorbidities would have coordinated, multidisciplinary care from admission to discharge, Dr. Fingado adds. Ideally, hospitals would have dedicated rooms or areas in the ED that are safe for patients and staff. Psychiatric patients who require observation or admission to a non-psychiatric hospital would be placed in rooms or units dedicated for psychiatric patients, again providing safety for patients and staff, Dr. Fingado surmises.

In addition, all staff members would have training in behavioral health management, including instruction on de-escalation, restraint techniques, and medication use for patients. Ideally, units would be staffed by specially trained aides, nurses, and healthcare providers (i.e., physician assistants, nurse practitioners, physicians), as well as psychologists and psychiatrists, Dr. Fingado says. This type of management would require buy-in from a multitude of groups, including healthcare administrators, nursing and provider staff, as well as health insurance companies. A reallocation or increase in funds would be needed to help build and staff these types of management models and locations, she adds.

In a perfect world, all hospitalized patients would be adequately screened for mental health issues and have their issues appropriately addressed by well-qualified professionals in real time, Dr. Grace says. Telemedicine services have great potential in helping to meet that goal, he says, and more relaxed regulatory guidelines around telemedicine could help make such physician-patient interactions less difficult. Many, if not most, hospitals currently have limited or no access to qualified mental health professionals, a conundrum based on supply, reimbursement, and need.

 

“Telemedicine, which is already having great success in neurology and intensive care unit medicine, is a great fit for this space,” Dr. Grace says. “Widespread access to a tele-psychiatrist would bring significant tangible benefits to patients, hospitals, hospital staff, and the population at large, who ultimately pay for healthcare in the nation.”

Dr. Horst says he believes everyone who treats psychiatric patients should have education in psychiatric medicine education. One way to achieve this would be to mandate continuing medical education coursework in mental health disorders.

The Reality of a Utopia

Traditionally, our healthcare system has been designed to react to illness, meaning that physicians treat illnesses when individuals become sick.

“But as science and technology now better understand the etiology of most illnesses, we are more equipped to design more preventative interventions rather than wait for individuals to become sick,” Dr. Bianco says. “Prevention interventions require an initial investment that the healthcare system is not necessarily willing to invest in at this time and a shift in the way it charges for services. If the healthcare system is unwilling to go that route, and we know we can prevent many illnesses by shifting the focus of treatment, consequently, human suffering is augmented and quality of life jeopardized.”

More recently, the general population and providers have acknowledged that healing takes place more effectively when it is applied in more integrated approaches (i.e., the utilization of the bio-psycho-social-spiritual model), Dr. Bianco adds. This greater appreciation is demonstrated by different research studies applied to different populations (both the general public and different providers). Despite this, the system (i.e., training) does not support a full integration of interventions.

“The system continues to operate under the traditional medical model that is fragmented and hyper-specialized,” Dr. Bianco says. “Science has demonstrated that the mind and the body work in more complex ways, requiring a more holistic approach to treatment. Although all segments among providers now understand and accept that, the system they dwell in does not support the daily challenges of treatment.

“Treatment continues to be fragmented as it is the medical model. At this point, at a minimum, a hospital should have a psychiatric department composed of individuals who are adequately trained (e.g., health psychology, behavioral medicine) to absorb a portion of individuals who primarily present with mental health issues.” TH

---

Karen Appold is a freelance medical writer in Pennsylvania.

References

1. Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Treatment Advocacy Center website. Available at: http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf. May 2010. Accessed August 18, 2015.
2. Results from the 2013 national survey on drug use and health: mental health detailed tables. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, U.S. Department of Health & Human Services website. Available at: http://www.samhsa.gov/data/sites/default/files/2013MHDetTabs/NSDUH-MHDetTabs2013.pdf. Accessed August 19, 2015.
3. Any mental illness among adults. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-adults.shtml. Accessed August 19, 2015.
4. Internal medicine certification examination blueprint. American Board of Internal Medicine website. Available at: https://www.abim.org/pdf/blueprint/im_cert.pdf. January 2015. Accessed August 19, 2015.

 

Case

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), hypertension, and alcohol use disorder (AUD) presents to the ED requesting alcohol detoxification. He has had six admissions in the last six months for alcohol detoxification. Two years ago, the patient had a documented alcohol withdrawal seizure. His last drink was eight hours ago, and he currently drinks a liter of vodka a day. On exam, his pulse rate is 126 bpm, and his blood pressure is 162/91 mm Hg. He appears anxious and has bilateral hand tremors. His serum ethanol level is 388.6 mg/dL.

Overview

DSM-5 integrated alcohol abuse and alcohol dependence that were previously classified in DSM-IV into AUDs with mild, moderate, and severe subclassifications. AUDs are the most serious substance abuse problem in the U.S. In the general population, the lifetime prevalence of alcohol abuse is 17.8% and of alcohol dependence is 12.5%.1–3 One study estimates that 24% of adult patients brought to the ED by ambulance suffer from alcoholism, and approximately 10% to 32% of hospitalized medical patients have an AUD.4–8 Patients who stop drinking will develop alcohol withdrawal as early as six hours after their last drink (see Figure 1). The majority of patients at risk of alcohol withdrawal syndrome (AWS) will develop only minor uncomplicated symptoms, but up to 20% will develop symptoms associated with complicated AWS, including withdrawal seizures and delirium tremens (DT).9 It is not entirely clear why some individuals suffer from more severe withdrawal symptoms than others, but genetic predisposition may play a role.10

DT is a syndrome characterized by agitation, disorientation, hallucinations, and autonomic instability (tachycardia, hypertension, hyperthermia, and diaphoresis) in the setting of acute reduction or abstinence from alcohol and is associated with a mortality rate as high as 20%.11 Complicated AWS is associated with increased in-hospital morbidity and mortality, longer lengths of stay, inflated costs of care, increased burden and frustration of nursing and medical staff, and worse cognitive functioning.9 In 80% of cases, the symptoms of uncomplicated alcohol withdrawal do not require aggressive medical intervention and usually disappear within two to seven days of the last drink.12 Physicians making triage decisions for patients who present to the ED in need of detoxification face a difficult dilemma concerning inpatient versus outpatient treatment.

Review of the Data

The literature on both inpatient and outpatient management and treatment of AWS is well-described. Currently, there are no guidelines or consensus on whether to admit patients with alcohol abuse syndromes to the hospital when the request for detoxification is made. Admission should be considered for all patients experiencing alcohol withdrawal who present to the ED.13 Patients with mild AWS may be discharged if they do not require admission for an additional medical condition, but patients experiencing moderate to severe withdrawal require admission for monitoring and treatment. Many physicians use a simple assessment of past history of DT and pulse rate, which may be easily evaluated in clinical settings, to readily identify patients who are at high risk of developing DT during an alcohol dependence period.14

Since 1978, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) has been consistently used for both monitoring patients with alcohol withdrawal and for making an initial assessment. CIWA-Ar was developed as a revised scale and is frequently used to monitor the severity of ongoing alcohol withdrawal and the response to treatment for the clinical care of patients in alcohol withdrawal (see Figure 2). CIWA-Ar was not developed to identify patients at risk for AWS but is frequently used to determine if patients require admission to the hospital for detoxification.15 Patients with CIWA-Ar scores > 15 require inpatient detoxification. Patients with scores between 8 and 15 should be admitted if they have a history of prior seizures or DT but could otherwise be considered for outpatient detoxification. Patients with scores < 8, which are considered mild alcohol withdrawal, can likely be safely treated as outpatients unless they have a history of DT or alcohol withdrawal seizures.16 Because symptoms of severe alcohol withdrawal are often not present for more than six hours after the patient’s last drink, or often longer, CIWA-Ar is limited and does not identify patients who are otherwise at high risk for complicated withdrawal. A protocol was developed incorporating the patient’s history of alcohol withdrawal seizure, DT, and the CIWA to evaluate the outcome of outpatient versus inpatient detoxification.16

 

 

The most promising tool to screen patients for AWS was developed recently by researchers at Stanford University in Stanford, Calif., using an extensive systematic literature search to identify evidence-based clinical factors associated with the development of AWS.15 The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was subsequently constructed from 10 items correlating with complicated AWS (see Figure 3). When using a PAWSS score cutoff of ≥ 4, the predictive value of identifying a patient who is at risk for complicated withdrawal is significantly increased to 93.1%. This tool has only been used in medically ill patients but could be extrapolated for use in patients who present to an acute-care setting requesting inpatient detoxification.

 

Patients presenting to the ED with alcohol withdrawal seizures have been shown to have an associated 35% risk of progression to DT when found to have a low platelet count, low blood pyridoxine, and a high blood level of homocysteine. In another retrospective cohort study in Hepatology, three clinical features were identified to be associated with an increased risk for DT: alcohol dependence, a prior history of DT, and a higher pulse rate at admission (> 100 bpm).14

Instructions for the assessment of the patient who requests detoxification are as follows:

1. A patient whose last drink of alcohol was more than five days ago and who shows no signs of withdrawal is unlikely to develop significant withdrawal symptoms and does not require inpatient detoxification.
2. Other medical and psychiatric conditions should be evaluated for admission including alcohol use disorder complications.
3. Calculate CIWA-Ar score:

   Scores < 8 may not need detoxification; consider calculating PAWSS score.

   Scores of 8 to 15 without symptoms of DT or seizures can be treated as an outpatient detoxification if no contraindication.

   Scores of ≥ 15 should be admitted to the hospital.

4. Calculate PAWSS score:

   Scores ≥ 4 suggest high risk for moderate to severe complicated AWS, and admission should be considered.

   Scores < 4 suggest lower risk for complicated AWS, and outpatient treatment should be considered if patients do not have a medical or surgical diagnosis requiring admission.

Back to the Case

At the time of his presentation, the patient was beginning to show signs of early withdrawal symptoms, including tremor and tachycardia, despite having an elevated blood alcohol level. This patient had a PAWSS score of 6, placing him at increased risk of complicated AWS, and a CIWA-Ar score of 13. He was subsequently admitted to the hospital, and symptom-triggered therapy for treatment of his alcohol withdrawal was used. The patient’s CIWA-Ar score peaked at 21 some 24 hours after his last drink. The patient otherwise had an uncomplicated four-day hospital course due to persistent nausea.

Bottom Line

Hospitalists unsure of which patients should be admitted for alcohol detoxification can use the PAWSS tool and an initial CIWA-Ar score to help determine a patient’s risk for developing complicated AWS. TH

---

Dr. Velasquez and Dr. Kornsawad are assistant professors and hospitalists at the University of Texas Health Science Center at San Antonio. Dr. Velasquez also serves as assistant professor and hospitalist at the South Texas Veterans Health Care System serving the San Antonio area.

References

1. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorder and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816.
2. Lieber CS. Medical disorders of alcoholism. N Engl J Med. 1995;333(16):1058-1065.
3. Hasin SD, Stinson SF, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830-842.
4. Whiteman PJ, Hoffman RS, Goldfrank LR. Alcoholism in the emergency department: an epidemiologic study. Acad Emerg Med. 2000;7(1):14-20.
5. Nielson SD, Storgarrd H, Moesgarrd F, Gluud C. Prevalence of alcohol problems among adult somatic in-patients of a Copenhagen hospital. Alcohol Alcohol. 1994;29(5):583-590.
6. Smothers BA, Yahr HT, Ruhl CE. Detection of alcohol use disorders in general hospital admissions in the United States. Arch Intern Med. 2004;164(7):749-756.
7. Dolman JM, Hawkes ND. Combining the audit questionnaire and biochemical markers to assess alcohol use and risk of alcohol withdrawal in medical inpatients. Alcohol Alcohol. 2005;40(6):515-519.
8. Doering-Silveira J, Fidalgo TM, Nascimento CL, et al. Assessing alcohol dependence in hospitalized patients. Int J Environ Res Public Health. 2014;11(6):5783-5791.
9. Maldonado JR, Sher Y, Das S, et al. Prospective validation study of the prediction of alcohol withdrawal severity scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol Alcohol. 2015;50(5):509-518.
10. Saitz R, O’Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am. 1997;81(4):881-907.
11. Turner RC, Lichstein PR, Pedan Jr JG, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432-444.
12. Schuckit MA. Alcohol-use disorders. Lancet. 2009;373(9662):492-501.
13. Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med. 2013;31(4):734-742.
14. Lee JH, Jang MK, Lee JY, et al. Clinical predictors for delirium tremens in alcohol dependence. J Gastroenterol Hepatol. 2005;20(12):1833-1837.
15. Maldonado JR, Sher Y, Ashouri JF, et al. The “prediction of alcohol withdrawal severity scale” (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48(4):375-390.
16. Stephens JR, Liles AE, Dancel R, Gilchrist M, Kirsch J, DeWalt DA. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med. 2014;29(4):587-593.

 

Case

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), hypertension, and alcohol use disorder (AUD) presents to the ED requesting alcohol detoxification. He has had six admissions in the last six months for alcohol detoxification. Two years ago, the patient had a documented alcohol withdrawal seizure. His last drink was eight hours ago, and he currently drinks a liter of vodka a day. On exam, his pulse rate is 126 bpm, and his blood pressure is 162/91 mm Hg. He appears anxious and has bilateral hand tremors. His serum ethanol level is 388.6 mg/dL.

Overview

DSM-5 integrated alcohol abuse and alcohol dependence that were previously classified in DSM-IV into AUDs with mild, moderate, and severe subclassifications. AUDs are the most serious substance abuse problem in the U.S. In the general population, the lifetime prevalence of alcohol abuse is 17.8% and of alcohol dependence is 12.5%.1–3 One study estimates that 24% of adult patients brought to the ED by ambulance suffer from alcoholism, and approximately 10% to 32% of hospitalized medical patients have an AUD.4–8 Patients who stop drinking will develop alcohol withdrawal as early as six hours after their last drink (see Figure 1). The majority of patients at risk of alcohol withdrawal syndrome (AWS) will develop only minor uncomplicated symptoms, but up to 20% will develop symptoms associated with complicated AWS, including withdrawal seizures and delirium tremens (DT).9 It is not entirely clear why some individuals suffer from more severe withdrawal symptoms than others, but genetic predisposition may play a role.10

DT is a syndrome characterized by agitation, disorientation, hallucinations, and autonomic instability (tachycardia, hypertension, hyperthermia, and diaphoresis) in the setting of acute reduction or abstinence from alcohol and is associated with a mortality rate as high as 20%.11 Complicated AWS is associated with increased in-hospital morbidity and mortality, longer lengths of stay, inflated costs of care, increased burden and frustration of nursing and medical staff, and worse cognitive functioning.9 In 80% of cases, the symptoms of uncomplicated alcohol withdrawal do not require aggressive medical intervention and usually disappear within two to seven days of the last drink.12 Physicians making triage decisions for patients who present to the ED in need of detoxification face a difficult dilemma concerning inpatient versus outpatient treatment.

Review of the Data

The literature on both inpatient and outpatient management and treatment of AWS is well-described. Currently, there are no guidelines or consensus on whether to admit patients with alcohol abuse syndromes to the hospital when the request for detoxification is made. Admission should be considered for all patients experiencing alcohol withdrawal who present to the ED.13 Patients with mild AWS may be discharged if they do not require admission for an additional medical condition, but patients experiencing moderate to severe withdrawal require admission for monitoring and treatment. Many physicians use a simple assessment of past history of DT and pulse rate, which may be easily evaluated in clinical settings, to readily identify patients who are at high risk of developing DT during an alcohol dependence period.14

Since 1978, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) has been consistently used for both monitoring patients with alcohol withdrawal and for making an initial assessment. CIWA-Ar was developed as a revised scale and is frequently used to monitor the severity of ongoing alcohol withdrawal and the response to treatment for the clinical care of patients in alcohol withdrawal (see Figure 2). CIWA-Ar was not developed to identify patients at risk for AWS but is frequently used to determine if patients require admission to the hospital for detoxification.15 Patients with CIWA-Ar scores > 15 require inpatient detoxification. Patients with scores between 8 and 15 should be admitted if they have a history of prior seizures or DT but could otherwise be considered for outpatient detoxification. Patients with scores < 8, which are considered mild alcohol withdrawal, can likely be safely treated as outpatients unless they have a history of DT or alcohol withdrawal seizures.16 Because symptoms of severe alcohol withdrawal are often not present for more than six hours after the patient’s last drink, or often longer, CIWA-Ar is limited and does not identify patients who are otherwise at high risk for complicated withdrawal. A protocol was developed incorporating the patient’s history of alcohol withdrawal seizure, DT, and the CIWA to evaluate the outcome of outpatient versus inpatient detoxification.16

 

 

The most promising tool to screen patients for AWS was developed recently by researchers at Stanford University in Stanford, Calif., using an extensive systematic literature search to identify evidence-based clinical factors associated with the development of AWS.15 The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was subsequently constructed from 10 items correlating with complicated AWS (see Figure 3). When using a PAWSS score cutoff of ≥ 4, the predictive value of identifying a patient who is at risk for complicated withdrawal is significantly increased to 93.1%. This tool has only been used in medically ill patients but could be extrapolated for use in patients who present to an acute-care setting requesting inpatient detoxification.

 

Patients presenting to the ED with alcohol withdrawal seizures have been shown to have an associated 35% risk of progression to DT when found to have a low platelet count, low blood pyridoxine, and a high blood level of homocysteine. In another retrospective cohort study in Hepatology, three clinical features were identified to be associated with an increased risk for DT: alcohol dependence, a prior history of DT, and a higher pulse rate at admission (> 100 bpm).14

Instructions for the assessment of the patient who requests detoxification are as follows:

1. A patient whose last drink of alcohol was more than five days ago and who shows no signs of withdrawal is unlikely to develop significant withdrawal symptoms and does not require inpatient detoxification.
2. Other medical and psychiatric conditions should be evaluated for admission including alcohol use disorder complications.
3. Calculate CIWA-Ar score:

   Scores < 8 may not need detoxification; consider calculating PAWSS score.

   Scores of 8 to 15 without symptoms of DT or seizures can be treated as an outpatient detoxification if no contraindication.

   Scores of ≥ 15 should be admitted to the hospital.

4. Calculate PAWSS score:

   Scores ≥ 4 suggest high risk for moderate to severe complicated AWS, and admission should be considered.

   Scores < 4 suggest lower risk for complicated AWS, and outpatient treatment should be considered if patients do not have a medical or surgical diagnosis requiring admission.

Back to the Case

At the time of his presentation, the patient was beginning to show signs of early withdrawal symptoms, including tremor and tachycardia, despite having an elevated blood alcohol level. This patient had a PAWSS score of 6, placing him at increased risk of complicated AWS, and a CIWA-Ar score of 13. He was subsequently admitted to the hospital, and symptom-triggered therapy for treatment of his alcohol withdrawal was used. The patient’s CIWA-Ar score peaked at 21 some 24 hours after his last drink. The patient otherwise had an uncomplicated four-day hospital course due to persistent nausea.

Bottom Line

Hospitalists unsure of which patients should be admitted for alcohol detoxification can use the PAWSS tool and an initial CIWA-Ar score to help determine a patient’s risk for developing complicated AWS. TH

---

Dr. Velasquez and Dr. Kornsawad are assistant professors and hospitalists at the University of Texas Health Science Center at San Antonio. Dr. Velasquez also serves as assistant professor and hospitalist at the South Texas Veterans Health Care System serving the San Antonio area.

References

1. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorder and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816.
2. Lieber CS. Medical disorders of alcoholism. N Engl J Med. 1995;333(16):1058-1065.
3. Hasin SD, Stinson SF, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830-842.
4. Whiteman PJ, Hoffman RS, Goldfrank LR. Alcoholism in the emergency department: an epidemiologic study. Acad Emerg Med. 2000;7(1):14-20.
5. Nielson SD, Storgarrd H, Moesgarrd F, Gluud C. Prevalence of alcohol problems among adult somatic in-patients of a Copenhagen hospital. Alcohol Alcohol. 1994;29(5):583-590.
6. Smothers BA, Yahr HT, Ruhl CE. Detection of alcohol use disorders in general hospital admissions in the United States. Arch Intern Med. 2004;164(7):749-756.
7. Dolman JM, Hawkes ND. Combining the audit questionnaire and biochemical markers to assess alcohol use and risk of alcohol withdrawal in medical inpatients. Alcohol Alcohol. 2005;40(6):515-519.
8. Doering-Silveira J, Fidalgo TM, Nascimento CL, et al. Assessing alcohol dependence in hospitalized patients. Int J Environ Res Public Health. 2014;11(6):5783-5791.
9. Maldonado JR, Sher Y, Das S, et al. Prospective validation study of the prediction of alcohol withdrawal severity scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol Alcohol. 2015;50(5):509-518.
10. Saitz R, O’Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am. 1997;81(4):881-907.
11. Turner RC, Lichstein PR, Pedan Jr JG, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432-444.
12. Schuckit MA. Alcohol-use disorders. Lancet. 2009;373(9662):492-501.
13. Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med. 2013;31(4):734-742.
14. Lee JH, Jang MK, Lee JY, et al. Clinical predictors for delirium tremens in alcohol dependence. J Gastroenterol Hepatol. 2005;20(12):1833-1837.
15. Maldonado JR, Sher Y, Ashouri JF, et al. The “prediction of alcohol withdrawal severity scale” (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48(4):375-390.
16. Stephens JR, Liles AE, Dancel R, Gilchrist M, Kirsch J, DeWalt DA. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med. 2014;29(4):587-593.

 

Case

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), hypertension, and alcohol use disorder (AUD) presents to the ED requesting alcohol detoxification. He has had six admissions in the last six months for alcohol detoxification. Two years ago, the patient had a documented alcohol withdrawal seizure. His last drink was eight hours ago, and he currently drinks a liter of vodka a day. On exam, his pulse rate is 126 bpm, and his blood pressure is 162/91 mm Hg. He appears anxious and has bilateral hand tremors. His serum ethanol level is 388.6 mg/dL.

Overview

DSM-5 integrated alcohol abuse and alcohol dependence that were previously classified in DSM-IV into AUDs with mild, moderate, and severe subclassifications. AUDs are the most serious substance abuse problem in the U.S. In the general population, the lifetime prevalence of alcohol abuse is 17.8% and of alcohol dependence is 12.5%.1–3 One study estimates that 24% of adult patients brought to the ED by ambulance suffer from alcoholism, and approximately 10% to 32% of hospitalized medical patients have an AUD.4–8 Patients who stop drinking will develop alcohol withdrawal as early as six hours after their last drink (see Figure 1). The majority of patients at risk of alcohol withdrawal syndrome (AWS) will develop only minor uncomplicated symptoms, but up to 20% will develop symptoms associated with complicated AWS, including withdrawal seizures and delirium tremens (DT).9 It is not entirely clear why some individuals suffer from more severe withdrawal symptoms than others, but genetic predisposition may play a role.10

DT is a syndrome characterized by agitation, disorientation, hallucinations, and autonomic instability (tachycardia, hypertension, hyperthermia, and diaphoresis) in the setting of acute reduction or abstinence from alcohol and is associated with a mortality rate as high as 20%.11 Complicated AWS is associated with increased in-hospital morbidity and mortality, longer lengths of stay, inflated costs of care, increased burden and frustration of nursing and medical staff, and worse cognitive functioning.9 In 80% of cases, the symptoms of uncomplicated alcohol withdrawal do not require aggressive medical intervention and usually disappear within two to seven days of the last drink.12 Physicians making triage decisions for patients who present to the ED in need of detoxification face a difficult dilemma concerning inpatient versus outpatient treatment.

Review of the Data

The literature on both inpatient and outpatient management and treatment of AWS is well-described. Currently, there are no guidelines or consensus on whether to admit patients with alcohol abuse syndromes to the hospital when the request for detoxification is made. Admission should be considered for all patients experiencing alcohol withdrawal who present to the ED.13 Patients with mild AWS may be discharged if they do not require admission for an additional medical condition, but patients experiencing moderate to severe withdrawal require admission for monitoring and treatment. Many physicians use a simple assessment of past history of DT and pulse rate, which may be easily evaluated in clinical settings, to readily identify patients who are at high risk of developing DT during an alcohol dependence period.14

Since 1978, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) has been consistently used for both monitoring patients with alcohol withdrawal and for making an initial assessment. CIWA-Ar was developed as a revised scale and is frequently used to monitor the severity of ongoing alcohol withdrawal and the response to treatment for the clinical care of patients in alcohol withdrawal (see Figure 2). CIWA-Ar was not developed to identify patients at risk for AWS but is frequently used to determine if patients require admission to the hospital for detoxification.15 Patients with CIWA-Ar scores > 15 require inpatient detoxification. Patients with scores between 8 and 15 should be admitted if they have a history of prior seizures or DT but could otherwise be considered for outpatient detoxification. Patients with scores < 8, which are considered mild alcohol withdrawal, can likely be safely treated as outpatients unless they have a history of DT or alcohol withdrawal seizures.16 Because symptoms of severe alcohol withdrawal are often not present for more than six hours after the patient’s last drink, or often longer, CIWA-Ar is limited and does not identify patients who are otherwise at high risk for complicated withdrawal. A protocol was developed incorporating the patient’s history of alcohol withdrawal seizure, DT, and the CIWA to evaluate the outcome of outpatient versus inpatient detoxification.16

 

 

The most promising tool to screen patients for AWS was developed recently by researchers at Stanford University in Stanford, Calif., using an extensive systematic literature search to identify evidence-based clinical factors associated with the development of AWS.15 The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was subsequently constructed from 10 items correlating with complicated AWS (see Figure 3). When using a PAWSS score cutoff of ≥ 4, the predictive value of identifying a patient who is at risk for complicated withdrawal is significantly increased to 93.1%. This tool has only been used in medically ill patients but could be extrapolated for use in patients who present to an acute-care setting requesting inpatient detoxification.

 

Patients presenting to the ED with alcohol withdrawal seizures have been shown to have an associated 35% risk of progression to DT when found to have a low platelet count, low blood pyridoxine, and a high blood level of homocysteine. In another retrospective cohort study in Hepatology, three clinical features were identified to be associated with an increased risk for DT: alcohol dependence, a prior history of DT, and a higher pulse rate at admission (> 100 bpm).14

Instructions for the assessment of the patient who requests detoxification are as follows:

1. A patient whose last drink of alcohol was more than five days ago and who shows no signs of withdrawal is unlikely to develop significant withdrawal symptoms and does not require inpatient detoxification.
2. Other medical and psychiatric conditions should be evaluated for admission including alcohol use disorder complications.
3. Calculate CIWA-Ar score:

   Scores < 8 may not need detoxification; consider calculating PAWSS score.

   Scores of 8 to 15 without symptoms of DT or seizures can be treated as an outpatient detoxification if no contraindication.

   Scores of ≥ 15 should be admitted to the hospital.

4. Calculate PAWSS score:

   Scores ≥ 4 suggest high risk for moderate to severe complicated AWS, and admission should be considered.

   Scores < 4 suggest lower risk for complicated AWS, and outpatient treatment should be considered if patients do not have a medical or surgical diagnosis requiring admission.

Back to the Case

At the time of his presentation, the patient was beginning to show signs of early withdrawal symptoms, including tremor and tachycardia, despite having an elevated blood alcohol level. This patient had a PAWSS score of 6, placing him at increased risk of complicated AWS, and a CIWA-Ar score of 13. He was subsequently admitted to the hospital, and symptom-triggered therapy for treatment of his alcohol withdrawal was used. The patient’s CIWA-Ar score peaked at 21 some 24 hours after his last drink. The patient otherwise had an uncomplicated four-day hospital course due to persistent nausea.

Bottom Line

Hospitalists unsure of which patients should be admitted for alcohol detoxification can use the PAWSS tool and an initial CIWA-Ar score to help determine a patient’s risk for developing complicated AWS. TH

---

Dr. Velasquez and Dr. Kornsawad are assistant professors and hospitalists at the University of Texas Health Science Center at San Antonio. Dr. Velasquez also serves as assistant professor and hospitalist at the South Texas Veterans Health Care System serving the San Antonio area.

References

1. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorder and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816.
2. Lieber CS. Medical disorders of alcoholism. N Engl J Med. 1995;333(16):1058-1065.
3. Hasin SD, Stinson SF, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830-842.
4. Whiteman PJ, Hoffman RS, Goldfrank LR. Alcoholism in the emergency department: an epidemiologic study. Acad Emerg Med. 2000;7(1):14-20.
5. Nielson SD, Storgarrd H, Moesgarrd F, Gluud C. Prevalence of alcohol problems among adult somatic in-patients of a Copenhagen hospital. Alcohol Alcohol. 1994;29(5):583-590.
6. Smothers BA, Yahr HT, Ruhl CE. Detection of alcohol use disorders in general hospital admissions in the United States. Arch Intern Med. 2004;164(7):749-756.
7. Dolman JM, Hawkes ND. Combining the audit questionnaire and biochemical markers to assess alcohol use and risk of alcohol withdrawal in medical inpatients. Alcohol Alcohol. 2005;40(6):515-519.
8. Doering-Silveira J, Fidalgo TM, Nascimento CL, et al. Assessing alcohol dependence in hospitalized patients. Int J Environ Res Public Health. 2014;11(6):5783-5791.
9. Maldonado JR, Sher Y, Das S, et al. Prospective validation study of the prediction of alcohol withdrawal severity scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol Alcohol. 2015;50(5):509-518.
10. Saitz R, O’Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am. 1997;81(4):881-907.
11. Turner RC, Lichstein PR, Pedan Jr JG, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432-444.
12. Schuckit MA. Alcohol-use disorders. Lancet. 2009;373(9662):492-501.
13. Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med. 2013;31(4):734-742.
14. Lee JH, Jang MK, Lee JY, et al. Clinical predictors for delirium tremens in alcohol dependence. J Gastroenterol Hepatol. 2005;20(12):1833-1837.
15. Maldonado JR, Sher Y, Ashouri JF, et al. The “prediction of alcohol withdrawal severity scale” (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48(4):375-390.
16. Stephens JR, Liles AE, Dancel R, Gilchrist M, Kirsch J, DeWalt DA. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med. 2014;29(4):587-593.

 

The Focused Practice in Hospital Medicine exam is just two months away (May 17). Have you started your preparation?

SHM recently developed the only maintenance of certification (MOC) exam by hospitalists for hospitalists. SHM SPARK is a fantastic complement to MOC tools already on the market and will help hospitalists succeed in the upcoming exam; it delivers access to relevant hospital medicine review content to enhance patient care while at the same time giving you the flexibility to fill your knowledge gaps and study needs at your own pace.

Featuring a unique online platform, SHM SPARK offers 175 vignette-style multiple-choice questions that bridge the primary knowledge gaps found within existing MOC exam-preparation products today. Other preparation tools are targeted toward the ABIM Internal Medicine exam and cover only roughly 60% of the Focused Practice in Hospital Medicine exam.

SHM SPARK is designed to serve as a supplemental study guide providing targeted study in the remaining roughly 40% of the Focused Practice in Hospital Medicine exam blueprint.

SHM SPARK provides in-depth review on the following systems-based content:

• Palliative care, ethics, and decision making
• Patient safety
• Perioperative care and consultative co-management
• Quality, cost, and clinical reasoning

The tool’s self-study provides detailed learning objectives and discussion points and allows users to define individual areas of strengths and weaknesses. Users will have the option to claim applicable ABIM MOC Part II Medical Knowledge points as they complete each module with a minimum passing score of 80%. After successful completion of all four modules, participants may claim up to 10.5 AMA PRA Category 1 Credits.

Order SPARK today at www.hospitalmedicine.org/SPARK.

The Focused Practice in Hospital Medicine exam is just two months away (May 17). Have you started your preparation?

SHM recently developed the only maintenance of certification (MOC) exam by hospitalists for hospitalists. SHM SPARK is a fantastic complement to MOC tools already on the market and will help hospitalists succeed in the upcoming exam; it delivers access to relevant hospital medicine review content to enhance patient care while at the same time giving you the flexibility to fill your knowledge gaps and study needs at your own pace.

Featuring a unique online platform, SHM SPARK offers 175 vignette-style multiple-choice questions that bridge the primary knowledge gaps found within existing MOC exam-preparation products today. Other preparation tools are targeted toward the ABIM Internal Medicine exam and cover only roughly 60% of the Focused Practice in Hospital Medicine exam.

SHM SPARK is designed to serve as a supplemental study guide providing targeted study in the remaining roughly 40% of the Focused Practice in Hospital Medicine exam blueprint.

SHM SPARK provides in-depth review on the following systems-based content:

• Palliative care, ethics, and decision making
• Patient safety
• Perioperative care and consultative co-management
• Quality, cost, and clinical reasoning

The tool’s self-study provides detailed learning objectives and discussion points and allows users to define individual areas of strengths and weaknesses. Users will have the option to claim applicable ABIM MOC Part II Medical Knowledge points as they complete each module with a minimum passing score of 80%. After successful completion of all four modules, participants may claim up to 10.5 AMA PRA Category 1 Credits.

Order SPARK today at www.hospitalmedicine.org/SPARK.

The Focused Practice in Hospital Medicine exam is just two months away (May 17). Have you started your preparation?

SHM recently developed the only maintenance of certification (MOC) exam by hospitalists for hospitalists. SHM SPARK is a fantastic complement to MOC tools already on the market and will help hospitalists succeed in the upcoming exam; it delivers access to relevant hospital medicine review content to enhance patient care while at the same time giving you the flexibility to fill your knowledge gaps and study needs at your own pace.

Featuring a unique online platform, SHM SPARK offers 175 vignette-style multiple-choice questions that bridge the primary knowledge gaps found within existing MOC exam-preparation products today. Other preparation tools are targeted toward the ABIM Internal Medicine exam and cover only roughly 60% of the Focused Practice in Hospital Medicine exam.

SHM SPARK is designed to serve as a supplemental study guide providing targeted study in the remaining roughly 40% of the Focused Practice in Hospital Medicine exam blueprint.

SHM SPARK provides in-depth review on the following systems-based content:

• Palliative care, ethics, and decision making
• Patient safety
• Perioperative care and consultative co-management
• Quality, cost, and clinical reasoning

The tool’s self-study provides detailed learning objectives and discussion points and allows users to define individual areas of strengths and weaknesses. Users will have the option to claim applicable ABIM MOC Part II Medical Knowledge points as they complete each module with a minimum passing score of 80%. After successful completion of all four modules, participants may claim up to 10.5 AMA PRA Category 1 Credits.

Order SPARK today at www.hospitalmedicine.org/SPARK.

Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.

This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.

What Is MIPS?

MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.

Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.

The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.

A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.

What Are APMs?

The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.

To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.

Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.

 

Stick with MIPS? Or Take the Plunge with APM?

How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.

Let’s look at a few scenarios:

Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.

Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.

In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.

Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.

Is MACRA Good for Hospitalists?

Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.

With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.

For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.

With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.

What Issues Should Hospitalists Be Aware Of?

As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.

A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.

 

In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.

SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.

To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.

Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.

What’s Next?

Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.

SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH

---

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.

Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.

This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.

What Is MIPS?

MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.

Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.

The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.

A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.

What Are APMs?

The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.

To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.

Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.

 

Stick with MIPS? Or Take the Plunge with APM?

How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.

Let’s look at a few scenarios:

Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.

Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.

In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.

Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.

Is MACRA Good for Hospitalists?

Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.

With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.

For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.

With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.

What Issues Should Hospitalists Be Aware Of?

As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.

A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.

 

In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.

SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.

To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.

Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.

What’s Next?

Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.

SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH

---

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.

Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.

This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.

What Is MIPS?

MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.

Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.

The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.

A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.

What Are APMs?

The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.

To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.

Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.

 

Stick with MIPS? Or Take the Plunge with APM?

How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.

Let’s look at a few scenarios:

Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.

Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.

In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.

Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.

Is MACRA Good for Hospitalists?

Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.

With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.

For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.

With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.

What Issues Should Hospitalists Be Aware Of?

As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.

A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.

 

In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.

SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.

To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.

Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.

What’s Next?

Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.

SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH

---

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.

When developing the “Fight the Resistance” campaign last year, the SHM team knew that antibiotic resistance would continue to be one of the most high-profile medical concerns heading into 2016. To promote appropriate antibiotic prescribing, SHM worked with its members to establish the following recommendations for clinicians and other hospital-based staff to promote awareness and inspire a dialogue around antibiotic stewardship:

• Identify opportunities to engage with all hospital-based clinicians to improve antibiotic stewardship in your hospital.
• Pay attention to appropriate antibiotic choice and resistance patterns and identify mechanisms to educate providers on overprescribing in your hospital.
• Consider the following:

  Adhere to antibiotic treatment guidelines.

  Track the day.

  Set a stop date.

  Reevaluate therapy.

  Streamline therapy.

  Avoid automatic time courses.

As part of this initiative, SHM designed a series of posters inspired by the propaganda style of the early 20th century to display the recommendations and asked for your help to join the fight through SHM’s first Twitter contest. The support and enthusiasm from members and nonmembers alike were contagious! To enter, participants took a photo of themselves and their teams hanging a “Fight the Resistance” poster in their hospitals or offices, then tweeted the photo with the #FightTheResistance hashtag to @SHMLive.

Not only did participants receive recognition for their efforts hanging up the posters and engaging their teams, the posters’ presence in various hospitals and offices around the country created thousands of impressions among hospital-based staff and others directly responsible for proper antibiotic prescribing.

Although the contest is over, you can still help facilitate culture change related to appropriate antibiotic prescribing. Follow SHM on Twitter @SHMLive, and continue to visit FightTheResistance.org for the latest updates on the campaign and new tools to promote antibiotic stewardship. TH

---

Brett Radler is SHM’s communications coordinator.

When developing the “Fight the Resistance” campaign last year, the SHM team knew that antibiotic resistance would continue to be one of the most high-profile medical concerns heading into 2016. To promote appropriate antibiotic prescribing, SHM worked with its members to establish the following recommendations for clinicians and other hospital-based staff to promote awareness and inspire a dialogue around antibiotic stewardship:

• Identify opportunities to engage with all hospital-based clinicians to improve antibiotic stewardship in your hospital.
• Pay attention to appropriate antibiotic choice and resistance patterns and identify mechanisms to educate providers on overprescribing in your hospital.
• Consider the following:

  Adhere to antibiotic treatment guidelines.

  Track the day.

  Set a stop date.

  Reevaluate therapy.

  Streamline therapy.

  Avoid automatic time courses.

As part of this initiative, SHM designed a series of posters inspired by the propaganda style of the early 20th century to display the recommendations and asked for your help to join the fight through SHM’s first Twitter contest. The support and enthusiasm from members and nonmembers alike were contagious! To enter, participants took a photo of themselves and their teams hanging a “Fight the Resistance” poster in their hospitals or offices, then tweeted the photo with the #FightTheResistance hashtag to @SHMLive.

Not only did participants receive recognition for their efforts hanging up the posters and engaging their teams, the posters’ presence in various hospitals and offices around the country created thousands of impressions among hospital-based staff and others directly responsible for proper antibiotic prescribing.

Although the contest is over, you can still help facilitate culture change related to appropriate antibiotic prescribing. Follow SHM on Twitter @SHMLive, and continue to visit FightTheResistance.org for the latest updates on the campaign and new tools to promote antibiotic stewardship. TH

---

Brett Radler is SHM’s communications coordinator.

When developing the “Fight the Resistance” campaign last year, the SHM team knew that antibiotic resistance would continue to be one of the most high-profile medical concerns heading into 2016. To promote appropriate antibiotic prescribing, SHM worked with its members to establish the following recommendations for clinicians and other hospital-based staff to promote awareness and inspire a dialogue around antibiotic stewardship:

• Identify opportunities to engage with all hospital-based clinicians to improve antibiotic stewardship in your hospital.
• Pay attention to appropriate antibiotic choice and resistance patterns and identify mechanisms to educate providers on overprescribing in your hospital.
• Consider the following:

  Adhere to antibiotic treatment guidelines.

  Track the day.

  Set a stop date.

  Reevaluate therapy.

  Streamline therapy.

  Avoid automatic time courses.

As part of this initiative, SHM designed a series of posters inspired by the propaganda style of the early 20th century to display the recommendations and asked for your help to join the fight through SHM’s first Twitter contest. The support and enthusiasm from members and nonmembers alike were contagious! To enter, participants took a photo of themselves and their teams hanging a “Fight the Resistance” poster in their hospitals or offices, then tweeted the photo with the #FightTheResistance hashtag to @SHMLive.

Not only did participants receive recognition for their efforts hanging up the posters and engaging their teams, the posters’ presence in various hospitals and offices around the country created thousands of impressions among hospital-based staff and others directly responsible for proper antibiotic prescribing.

Although the contest is over, you can still help facilitate culture change related to appropriate antibiotic prescribing. Follow SHM on Twitter @SHMLive, and continue to visit FightTheResistance.org for the latest updates on the campaign and new tools to promote antibiotic stewardship. TH

---

Brett Radler is SHM’s communications coordinator.

The Society of Hospital Medicine (SHM) created the Awards of Excellence Program to honor its members whose exemplary contributions to the hospital medicine movement merit acknowledgment and celebration. In honor of their achievements, recipients of each Award of Excellence receive an all-expense paid trip to SHM’s annual meeting.

Award recipients also receive recognition on stage in front of friends, family, and colleagues at SHM’s annual meeting, in The Hospitalist, and on www.hospitalmedicine.org.

Congratulations to this year’s winners:

Clinical Excellence

Mark Thoelke, MD, SFHM

Dr. Thoelke became the first hospitalist at Barnes-Jewish Hospital in 1998 and helped form the Hospital Medicine Division of the Washington University School of Medicine in St. Louis in 2000, one of the first divisions in the U.S. The division is now composed of 70 physicians and eight nurse practitioners and consistently turns in superior performances on clinical outcomes as measured by UnitedHealthcare. The division has led the way with innovations in care models and teaching models and was one of the first to offer a sub-internship experience on the non-teaching service and one of the first to offer co-management with their oncology service in 2002. Dr. Thoelke still spends two-thirds of his time on clinical services and states that his job satisfaction comes largely from patient care and teaching.

Humanitarian Services

Bijay Acharya, MBBS, MD

Dr. Acharya works as a hospitalist at Massachusetts General Hospital in Boston and is currently completing the Harvard Medical School/CRICO Fellowship in Patient Safety and Quality. His humanitarian work started when he was in medical school, where he led many health camps in extremely poor villages, ran blood-donation drives, and established the poor-patient fund. After graduation, Dr. Acharya, with his friends, worked to establish a nonprofit clinic named NyayaHealth (now Possible) to serve the healthcare needs of a very remote district in rural Nepal. Prior to the clinic, there was no physician for more than a quarter million people. Recently, after the massive earthquake in Nepal, Dr. Acharya led the relief efforts for the earthquake victims. Dr. Acharya strongly believes in the capacity of hospitalists to be strong advocates for their patients, peers, and communities, both locally and globally.

Non-Physician

Tiffani M. Panek, MA, SFHM, CLHM

Panek is the hospitalist administrator for the Division of Hospital Medicine at the Johns Hopkins Bayview Medical Center in Baltimore. She is a Senior Fellow in Hospital Medicine and has also received her Certificate of Leadership in Hospital Medicine (CLHM) from SHM. She has been at Johns Hopkins for more than 12 years and has been instrumental in the significant growth and success of the Division of Hospital Medicine. Within SHM, she has been a member of the Practice Administrators Committee for three years and was recently elected to a two-year term as vice president of SHM’s Maryland Chapter. She is the first administrator to be elected to chapter leadership, to receive the CLHM, and to have an abstract accepted at an SHM annual meeting.

Outstanding Service

Thomas McIlraith, MD, SFHM, CLHM

Dr. McIlraith is the chairman of the Hospital Medicine Department at Mercy Medical Group in Sacramento, Calif. He improved patient flow between admissions and rounding with a novel operational system called Central Coordination, and it is now the standard for the Dignity Health facilities in Sacramento. The system markedly improved ED response, on-call hospitalist stress, and patient continuity. He has led many other quality and operational improvements, including unit-based rounding, rapid-response team development, and staff restructuring to improve physician coverage. Most recently, he became a leader in the Patient Experience Movement by developing the “Cognitive/Emotional Disconnect” model for understanding patient experience in hospital medicine. He is a member of the SHM Practice Management Committee.

 

Research

Vineet Chopra, MD, MSc, FHM

Dr. Chopra is an assistant professor of medicine and research scientist in the Patient Safety Enhancement Program at the University of Michigan and Ann Arbor VA Medical Center. Dr. Chopra’s research efforts are centered on improving the safety of hospitalized patients by preventing hospital-acquired complications. Using peripherally inserted central catheters (PICCs) as a model for this inquiry, his work has focused on quantifying current use of PICCs in hospitalized patients, estimating the risk of complications, and defining innovative ways to improve decision making for these devices. His research has been cited 1,962 times (1,580 times since 2010). He is an associate editor of The American Journal of Medicine and the Journal of Hospital Medicine and will serve as chair of SHM’s Research Committee in 2016.

Teaching

Alberto Puig, MD, PhD, SFHM

Dr. Puig has spent his career fully devoted to medical and clinical education. He is an associate professor of medicine at Harvard Medical School in Boston and director of the core educator faculty in the Department of Medicine at Massachusetts General Hospital, where he leads a unique group of physician-teachers fully devoted to clinical education. He is a regular discussant on educational programs for the academy at Harvard Medical School, and his contributions to medical education and clinical hospital teaching have made him a celebrated teacher and educator. Dr. Puig has played an important role at SHM and in the field of hospital medicine through his efforts as a medical educator; he is an avid student of the history of medicine and has been a frequent presenter at SHM’s annual meeting on this topic.

Teamwork

WellSpan Health, Active Bed Management

Inspired by an HM12 pre-course on Active Bed Management (ABM), MaryEllen Pfeiffer, DO, physician lead for ABM at WellSpan, and William A. “Tex” Landis, MD, medical director of WellSpan Hospitalists, returned to York, Pa., and began brainstorming. After a site visit to Johns Hopkins Bayview Medical Center in Baltimore, a team of hospitalists collaborated with WellSpan nursing (Bonita Trapnell, RN), patient logistics (Marc Mione, RN), case management (Jessica Hagen, RN), and the ED (David Vega, MD, Brian Yetter, PhD) to pilot and implement ABM within WellSpan’s York and Gettysburg hospitals.

With the launch of ABM, Dr. Pfeiffer and Dr. Landis hoped to decrease ED length of stay by standardizing the hospitalist processes surrounding admission orders in computerized physician order entry. Ultimately, ABM at WellSpan has maintained the fastest time-to-admission order entry for any service at York Hospital—a decrease to 10 minutes from 80—with less variation for two years. ABM has also sustained national benchmark ED length of stay when the hospital is functioning at general capacity.

ABM also became instrumental in process and outcome objectives from a number of other hospital-wide initiatives. With ABM, more than 90% of a physician’s patient load is on one medical unit (up from 40%), which allowed the hospitalists to implement structured interdisciplinary bedside rounds (SIBR) on all medical units in York and Gettysburg hospitals. The success of ABM and SIBR allowed a transition-of-care project to focus on efficient discharges. Furthermore, Dr. Pfeiffer led a direct admission task force to improve direct admission referrals, safety, and acceptance, the number of which has since doubled. Without hospitalists’ ongoing leadership and effective teamwork, these significant improvements would not have been possible or sustained. TH

The Society of Hospital Medicine (SHM) created the Awards of Excellence Program to honor its members whose exemplary contributions to the hospital medicine movement merit acknowledgment and celebration. In honor of their achievements, recipients of each Award of Excellence receive an all-expense paid trip to SHM’s annual meeting.

Award recipients also receive recognition on stage in front of friends, family, and colleagues at SHM’s annual meeting, in The Hospitalist, and on www.hospitalmedicine.org.

Congratulations to this year’s winners:

Clinical Excellence

Mark Thoelke, MD, SFHM

Dr. Thoelke became the first hospitalist at Barnes-Jewish Hospital in 1998 and helped form the Hospital Medicine Division of the Washington University School of Medicine in St. Louis in 2000, one of the first divisions in the U.S. The division is now composed of 70 physicians and eight nurse practitioners and consistently turns in superior performances on clinical outcomes as measured by UnitedHealthcare. The division has led the way with innovations in care models and teaching models and was one of the first to offer a sub-internship experience on the non-teaching service and one of the first to offer co-management with their oncology service in 2002. Dr. Thoelke still spends two-thirds of his time on clinical services and states that his job satisfaction comes largely from patient care and teaching.

Humanitarian Services

Bijay Acharya, MBBS, MD

Dr. Acharya works as a hospitalist at Massachusetts General Hospital in Boston and is currently completing the Harvard Medical School/CRICO Fellowship in Patient Safety and Quality. His humanitarian work started when he was in medical school, where he led many health camps in extremely poor villages, ran blood-donation drives, and established the poor-patient fund. After graduation, Dr. Acharya, with his friends, worked to establish a nonprofit clinic named NyayaHealth (now Possible) to serve the healthcare needs of a very remote district in rural Nepal. Prior to the clinic, there was no physician for more than a quarter million people. Recently, after the massive earthquake in Nepal, Dr. Acharya led the relief efforts for the earthquake victims. Dr. Acharya strongly believes in the capacity of hospitalists to be strong advocates for their patients, peers, and communities, both locally and globally.

Non-Physician

Tiffani M. Panek, MA, SFHM, CLHM

Panek is the hospitalist administrator for the Division of Hospital Medicine at the Johns Hopkins Bayview Medical Center in Baltimore. She is a Senior Fellow in Hospital Medicine and has also received her Certificate of Leadership in Hospital Medicine (CLHM) from SHM. She has been at Johns Hopkins for more than 12 years and has been instrumental in the significant growth and success of the Division of Hospital Medicine. Within SHM, she has been a member of the Practice Administrators Committee for three years and was recently elected to a two-year term as vice president of SHM’s Maryland Chapter. She is the first administrator to be elected to chapter leadership, to receive the CLHM, and to have an abstract accepted at an SHM annual meeting.

Outstanding Service

Thomas McIlraith, MD, SFHM, CLHM

Dr. McIlraith is the chairman of the Hospital Medicine Department at Mercy Medical Group in Sacramento, Calif. He improved patient flow between admissions and rounding with a novel operational system called Central Coordination, and it is now the standard for the Dignity Health facilities in Sacramento. The system markedly improved ED response, on-call hospitalist stress, and patient continuity. He has led many other quality and operational improvements, including unit-based rounding, rapid-response team development, and staff restructuring to improve physician coverage. Most recently, he became a leader in the Patient Experience Movement by developing the “Cognitive/Emotional Disconnect” model for understanding patient experience in hospital medicine. He is a member of the SHM Practice Management Committee.

 

Research

Vineet Chopra, MD, MSc, FHM

Dr. Chopra is an assistant professor of medicine and research scientist in the Patient Safety Enhancement Program at the University of Michigan and Ann Arbor VA Medical Center. Dr. Chopra’s research efforts are centered on improving the safety of hospitalized patients by preventing hospital-acquired complications. Using peripherally inserted central catheters (PICCs) as a model for this inquiry, his work has focused on quantifying current use of PICCs in hospitalized patients, estimating the risk of complications, and defining innovative ways to improve decision making for these devices. His research has been cited 1,962 times (1,580 times since 2010). He is an associate editor of The American Journal of Medicine and the Journal of Hospital Medicine and will serve as chair of SHM’s Research Committee in 2016.

Teaching

Alberto Puig, MD, PhD, SFHM

Dr. Puig has spent his career fully devoted to medical and clinical education. He is an associate professor of medicine at Harvard Medical School in Boston and director of the core educator faculty in the Department of Medicine at Massachusetts General Hospital, where he leads a unique group of physician-teachers fully devoted to clinical education. He is a regular discussant on educational programs for the academy at Harvard Medical School, and his contributions to medical education and clinical hospital teaching have made him a celebrated teacher and educator. Dr. Puig has played an important role at SHM and in the field of hospital medicine through his efforts as a medical educator; he is an avid student of the history of medicine and has been a frequent presenter at SHM’s annual meeting on this topic.

Teamwork

WellSpan Health, Active Bed Management

Inspired by an HM12 pre-course on Active Bed Management (ABM), MaryEllen Pfeiffer, DO, physician lead for ABM at WellSpan, and William A. “Tex” Landis, MD, medical director of WellSpan Hospitalists, returned to York, Pa., and began brainstorming. After a site visit to Johns Hopkins Bayview Medical Center in Baltimore, a team of hospitalists collaborated with WellSpan nursing (Bonita Trapnell, RN), patient logistics (Marc Mione, RN), case management (Jessica Hagen, RN), and the ED (David Vega, MD, Brian Yetter, PhD) to pilot and implement ABM within WellSpan’s York and Gettysburg hospitals.

With the launch of ABM, Dr. Pfeiffer and Dr. Landis hoped to decrease ED length of stay by standardizing the hospitalist processes surrounding admission orders in computerized physician order entry. Ultimately, ABM at WellSpan has maintained the fastest time-to-admission order entry for any service at York Hospital—a decrease to 10 minutes from 80—with less variation for two years. ABM has also sustained national benchmark ED length of stay when the hospital is functioning at general capacity.

ABM also became instrumental in process and outcome objectives from a number of other hospital-wide initiatives. With ABM, more than 90% of a physician’s patient load is on one medical unit (up from 40%), which allowed the hospitalists to implement structured interdisciplinary bedside rounds (SIBR) on all medical units in York and Gettysburg hospitals. The success of ABM and SIBR allowed a transition-of-care project to focus on efficient discharges. Furthermore, Dr. Pfeiffer led a direct admission task force to improve direct admission referrals, safety, and acceptance, the number of which has since doubled. Without hospitalists’ ongoing leadership and effective teamwork, these significant improvements would not have been possible or sustained. TH

The Society of Hospital Medicine (SHM) created the Awards of Excellence Program to honor its members whose exemplary contributions to the hospital medicine movement merit acknowledgment and celebration. In honor of their achievements, recipients of each Award of Excellence receive an all-expense paid trip to SHM’s annual meeting.

Award recipients also receive recognition on stage in front of friends, family, and colleagues at SHM’s annual meeting, in The Hospitalist, and on www.hospitalmedicine.org.

Congratulations to this year’s winners:

Clinical Excellence

Mark Thoelke, MD, SFHM

Dr. Thoelke became the first hospitalist at Barnes-Jewish Hospital in 1998 and helped form the Hospital Medicine Division of the Washington University School of Medicine in St. Louis in 2000, one of the first divisions in the U.S. The division is now composed of 70 physicians and eight nurse practitioners and consistently turns in superior performances on clinical outcomes as measured by UnitedHealthcare. The division has led the way with innovations in care models and teaching models and was one of the first to offer a sub-internship experience on the non-teaching service and one of the first to offer co-management with their oncology service in 2002. Dr. Thoelke still spends two-thirds of his time on clinical services and states that his job satisfaction comes largely from patient care and teaching.

Humanitarian Services

Bijay Acharya, MBBS, MD

Dr. Acharya works as a hospitalist at Massachusetts General Hospital in Boston and is currently completing the Harvard Medical School/CRICO Fellowship in Patient Safety and Quality. His humanitarian work started when he was in medical school, where he led many health camps in extremely poor villages, ran blood-donation drives, and established the poor-patient fund. After graduation, Dr. Acharya, with his friends, worked to establish a nonprofit clinic named NyayaHealth (now Possible) to serve the healthcare needs of a very remote district in rural Nepal. Prior to the clinic, there was no physician for more than a quarter million people. Recently, after the massive earthquake in Nepal, Dr. Acharya led the relief efforts for the earthquake victims. Dr. Acharya strongly believes in the capacity of hospitalists to be strong advocates for their patients, peers, and communities, both locally and globally.

Non-Physician

Tiffani M. Panek, MA, SFHM, CLHM

Panek is the hospitalist administrator for the Division of Hospital Medicine at the Johns Hopkins Bayview Medical Center in Baltimore. She is a Senior Fellow in Hospital Medicine and has also received her Certificate of Leadership in Hospital Medicine (CLHM) from SHM. She has been at Johns Hopkins for more than 12 years and has been instrumental in the significant growth and success of the Division of Hospital Medicine. Within SHM, she has been a member of the Practice Administrators Committee for three years and was recently elected to a two-year term as vice president of SHM’s Maryland Chapter. She is the first administrator to be elected to chapter leadership, to receive the CLHM, and to have an abstract accepted at an SHM annual meeting.

Outstanding Service

Thomas McIlraith, MD, SFHM, CLHM

Dr. McIlraith is the chairman of the Hospital Medicine Department at Mercy Medical Group in Sacramento, Calif. He improved patient flow between admissions and rounding with a novel operational system called Central Coordination, and it is now the standard for the Dignity Health facilities in Sacramento. The system markedly improved ED response, on-call hospitalist stress, and patient continuity. He has led many other quality and operational improvements, including unit-based rounding, rapid-response team development, and staff restructuring to improve physician coverage. Most recently, he became a leader in the Patient Experience Movement by developing the “Cognitive/Emotional Disconnect” model for understanding patient experience in hospital medicine. He is a member of the SHM Practice Management Committee.

 

Research

Vineet Chopra, MD, MSc, FHM

Dr. Chopra is an assistant professor of medicine and research scientist in the Patient Safety Enhancement Program at the University of Michigan and Ann Arbor VA Medical Center. Dr. Chopra’s research efforts are centered on improving the safety of hospitalized patients by preventing hospital-acquired complications. Using peripherally inserted central catheters (PICCs) as a model for this inquiry, his work has focused on quantifying current use of PICCs in hospitalized patients, estimating the risk of complications, and defining innovative ways to improve decision making for these devices. His research has been cited 1,962 times (1,580 times since 2010). He is an associate editor of The American Journal of Medicine and the Journal of Hospital Medicine and will serve as chair of SHM’s Research Committee in 2016.

Teaching

Alberto Puig, MD, PhD, SFHM

Dr. Puig has spent his career fully devoted to medical and clinical education. He is an associate professor of medicine at Harvard Medical School in Boston and director of the core educator faculty in the Department of Medicine at Massachusetts General Hospital, where he leads a unique group of physician-teachers fully devoted to clinical education. He is a regular discussant on educational programs for the academy at Harvard Medical School, and his contributions to medical education and clinical hospital teaching have made him a celebrated teacher and educator. Dr. Puig has played an important role at SHM and in the field of hospital medicine through his efforts as a medical educator; he is an avid student of the history of medicine and has been a frequent presenter at SHM’s annual meeting on this topic.

Teamwork

WellSpan Health, Active Bed Management

Inspired by an HM12 pre-course on Active Bed Management (ABM), MaryEllen Pfeiffer, DO, physician lead for ABM at WellSpan, and William A. “Tex” Landis, MD, medical director of WellSpan Hospitalists, returned to York, Pa., and began brainstorming. After a site visit to Johns Hopkins Bayview Medical Center in Baltimore, a team of hospitalists collaborated with WellSpan nursing (Bonita Trapnell, RN), patient logistics (Marc Mione, RN), case management (Jessica Hagen, RN), and the ED (David Vega, MD, Brian Yetter, PhD) to pilot and implement ABM within WellSpan’s York and Gettysburg hospitals.

With the launch of ABM, Dr. Pfeiffer and Dr. Landis hoped to decrease ED length of stay by standardizing the hospitalist processes surrounding admission orders in computerized physician order entry. Ultimately, ABM at WellSpan has maintained the fastest time-to-admission order entry for any service at York Hospital—a decrease to 10 minutes from 80—with less variation for two years. ABM has also sustained national benchmark ED length of stay when the hospital is functioning at general capacity.

ABM also became instrumental in process and outcome objectives from a number of other hospital-wide initiatives. With ABM, more than 90% of a physician’s patient load is on one medical unit (up from 40%), which allowed the hospitalists to implement structured interdisciplinary bedside rounds (SIBR) on all medical units in York and Gettysburg hospitals. The success of ABM and SIBR allowed a transition-of-care project to focus on efficient discharges. Furthermore, Dr. Pfeiffer led a direct admission task force to improve direct admission referrals, safety, and acceptance, the number of which has since doubled. Without hospitalists’ ongoing leadership and effective teamwork, these significant improvements would not have been possible or sustained. TH

By January 2016, 31 states and the District of Columbia had embraced the Medicaid expansion brought to bear by the Affordable Care Act. Three states had not expanded but were “in active discussion,” while 16 states continued to opt out.1

The impacts of those decisions—on hospitals, on patients, and on physicians—are now beginning to be emerge. Several early studies, published toward the end of 2015 and in early 2016, show how the choice to expand or not expand impacted payor mix, patient access to quality healthcare, and physician reimbursement.

A study published in Health Affairs found states that expanded Medicaid in 2014, including Minnesota, Kentucky, and Arizona, saw a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. In six states that did not expand that year, including Florida, Georgia, and Missouri, there was no significant change in payor mix.2

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

Instant Impact

Dr. Nikpay and the research team at the University of Michigan Institute for Healthcare Policy & Innovation (where she was previously a postdoctoral researcher) utilized a free online tool, HCUP Fast Stats (Healthcare Cost and Utilization Project), from the Agency for Healthcare Research and Quality. They examined adult discharges by quarter in 2013 and 2014 in each state in the study, controlling for demographic and economic characteristics.

Expansion states, the team learned, experienced a seven percentage point rise in Medicaid shares and a six percentage point drop in uninsured shares, reflecting a respective 20% increase in Medicaid discharges and 50% decrease in uninsured discharges. The effect was particularly profound in Kentucky, which saw a 13.5% drop in uninsured shares.

This underscores the “significant benefits of Medicaid expansion for low-income adults and for the hospitals that serve them,” the study authors concluded.

With positive data from this study and others—and the federal government willing to work with states on alternative expansion models, like in Arkansas, which is using Medicaid dollars to subsidize private insurance for recipients—Colleen M. Grogan, professor in the School of Social Service Administration at The University of Chicago, says the remaining states may feel more pressure to expand.

They are “getting pressure from hospitals and the business sector,” Grogan says. “It has an enormous impact on the economy. I don’t think any state is exempt from economic impact when they give up an infusion of federal funds.”

The federal government currently pays 100% of state Medicaid costs for the newly eligible upon expansion, eventually dropping to 90% by 2020.

A January 2016 Health Affairs study from researchers at Harvard University and Brigham and Women’s Hospital in Boston showed that traditional expansion in Kentucky and the “private option” expansion adopted in Arkansas both led to a decrease in the number of uninsured patients, an increase in access to healthcare, and fewer patients skipping medications or experiencing trouble paying medical bills between 2013 and expansion in 2014. This contrasted with the results in Texas, which has not expanded.3

Hospitalist Concerns

Patrick Cawley, MD, MBA, MHM, is CEO of the Medical University of South Carolina, previously practiced as a hospitalist, and is a past president of the Society of Hospital Medicine. For now, South Carolina is, like Texas, a non-expansion state. Dr. Cawley is concerned for the future of his hospital, an 800-bed academic, tertiary, safety-net hospital in Charleston, because payments to hospitals like his ultimately will drop.

 

Before a Supreme Court decision that ruled states were not compelled to expand Medicaid, the Affordable Care Act provided for a reduction in payments to safety-net hospitals. This was motivated by the notion that all hospitals would see a significant decrease in uncompensated care. The reduction has been delayed but is still scheduled to start in 2017.

“We couldn’t survive if disproportionate share goes away and something didn’t replace it, like Medicaid expansion,” Dr. Cawley says. But, he adds, over time he expects all or nearly all states will expand.

“When Medicaid first rolled out, it took 10 to 12 years before all states took it. I think expansion is the same way,” he says. “It’s one of those things that probably does work out, but what’s the transition going to be like, and how long is that transition going to last?” TH

---

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

References

1. Status of state action on the Medicaid expansion decision. Kaiser Family Foundation website. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Updated January 12, 2016. Accessed January 14, 2016.
2. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff. 2016;35(1):106-110. doi:10.1377/hlthaff.2015.1144.
3. Sommers BD, Blendon RJ, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff. 2016;35(1):96-105. doi:10.1377/hlthaff.2015.0917.
4. Jones CD, Scott SJ, Anoff DL, Pierce RG, Glasheen JJ. Changes in payer mix and physician reimbursement after the Affordable Care Act and Medicaid expansion. Inquiry. 2015;52. doi:10.1177/0046958015602464.

By January 2016, 31 states and the District of Columbia had embraced the Medicaid expansion brought to bear by the Affordable Care Act. Three states had not expanded but were “in active discussion,” while 16 states continued to opt out.1

The impacts of those decisions—on hospitals, on patients, and on physicians—are now beginning to be emerge. Several early studies, published toward the end of 2015 and in early 2016, show how the choice to expand or not expand impacted payor mix, patient access to quality healthcare, and physician reimbursement.

A study published in Health Affairs found states that expanded Medicaid in 2014, including Minnesota, Kentucky, and Arizona, saw a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. In six states that did not expand that year, including Florida, Georgia, and Missouri, there was no significant change in payor mix.2

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

Instant Impact

Dr. Nikpay and the research team at the University of Michigan Institute for Healthcare Policy & Innovation (where she was previously a postdoctoral researcher) utilized a free online tool, HCUP Fast Stats (Healthcare Cost and Utilization Project), from the Agency for Healthcare Research and Quality. They examined adult discharges by quarter in 2013 and 2014 in each state in the study, controlling for demographic and economic characteristics.

Expansion states, the team learned, experienced a seven percentage point rise in Medicaid shares and a six percentage point drop in uninsured shares, reflecting a respective 20% increase in Medicaid discharges and 50% decrease in uninsured discharges. The effect was particularly profound in Kentucky, which saw a 13.5% drop in uninsured shares.

This underscores the “significant benefits of Medicaid expansion for low-income adults and for the hospitals that serve them,” the study authors concluded.

With positive data from this study and others—and the federal government willing to work with states on alternative expansion models, like in Arkansas, which is using Medicaid dollars to subsidize private insurance for recipients—Colleen M. Grogan, professor in the School of Social Service Administration at The University of Chicago, says the remaining states may feel more pressure to expand.

They are “getting pressure from hospitals and the business sector,” Grogan says. “It has an enormous impact on the economy. I don’t think any state is exempt from economic impact when they give up an infusion of federal funds.”

The federal government currently pays 100% of state Medicaid costs for the newly eligible upon expansion, eventually dropping to 90% by 2020.

A January 2016 Health Affairs study from researchers at Harvard University and Brigham and Women’s Hospital in Boston showed that traditional expansion in Kentucky and the “private option” expansion adopted in Arkansas both led to a decrease in the number of uninsured patients, an increase in access to healthcare, and fewer patients skipping medications or experiencing trouble paying medical bills between 2013 and expansion in 2014. This contrasted with the results in Texas, which has not expanded.3

Hospitalist Concerns

Patrick Cawley, MD, MBA, MHM, is CEO of the Medical University of South Carolina, previously practiced as a hospitalist, and is a past president of the Society of Hospital Medicine. For now, South Carolina is, like Texas, a non-expansion state. Dr. Cawley is concerned for the future of his hospital, an 800-bed academic, tertiary, safety-net hospital in Charleston, because payments to hospitals like his ultimately will drop.

 

Before a Supreme Court decision that ruled states were not compelled to expand Medicaid, the Affordable Care Act provided for a reduction in payments to safety-net hospitals. This was motivated by the notion that all hospitals would see a significant decrease in uncompensated care. The reduction has been delayed but is still scheduled to start in 2017.

“We couldn’t survive if disproportionate share goes away and something didn’t replace it, like Medicaid expansion,” Dr. Cawley says. But, he adds, over time he expects all or nearly all states will expand.

“When Medicaid first rolled out, it took 10 to 12 years before all states took it. I think expansion is the same way,” he says. “It’s one of those things that probably does work out, but what’s the transition going to be like, and how long is that transition going to last?” TH

---

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

References

1. Status of state action on the Medicaid expansion decision. Kaiser Family Foundation website. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Updated January 12, 2016. Accessed January 14, 2016.
2. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff. 2016;35(1):106-110. doi:10.1377/hlthaff.2015.1144.
3. Sommers BD, Blendon RJ, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff. 2016;35(1):96-105. doi:10.1377/hlthaff.2015.0917.
4. Jones CD, Scott SJ, Anoff DL, Pierce RG, Glasheen JJ. Changes in payer mix and physician reimbursement after the Affordable Care Act and Medicaid expansion. Inquiry. 2015;52. doi:10.1177/0046958015602464.

By January 2016, 31 states and the District of Columbia had embraced the Medicaid expansion brought to bear by the Affordable Care Act. Three states had not expanded but were “in active discussion,” while 16 states continued to opt out.1

The impacts of those decisions—on hospitals, on patients, and on physicians—are now beginning to be emerge. Several early studies, published toward the end of 2015 and in early 2016, show how the choice to expand or not expand impacted payor mix, patient access to quality healthcare, and physician reimbursement.

A study published in Health Affairs found states that expanded Medicaid in 2014, including Minnesota, Kentucky, and Arizona, saw a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. In six states that did not expand that year, including Florida, Georgia, and Missouri, there was no significant change in payor mix.2

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

Instant Impact

Dr. Nikpay and the research team at the University of Michigan Institute for Healthcare Policy & Innovation (where she was previously a postdoctoral researcher) utilized a free online tool, HCUP Fast Stats (Healthcare Cost and Utilization Project), from the Agency for Healthcare Research and Quality. They examined adult discharges by quarter in 2013 and 2014 in each state in the study, controlling for demographic and economic characteristics.

Expansion states, the team learned, experienced a seven percentage point rise in Medicaid shares and a six percentage point drop in uninsured shares, reflecting a respective 20% increase in Medicaid discharges and 50% decrease in uninsured discharges. The effect was particularly profound in Kentucky, which saw a 13.5% drop in uninsured shares.

This underscores the “significant benefits of Medicaid expansion for low-income adults and for the hospitals that serve them,” the study authors concluded.

With positive data from this study and others—and the federal government willing to work with states on alternative expansion models, like in Arkansas, which is using Medicaid dollars to subsidize private insurance for recipients—Colleen M. Grogan, professor in the School of Social Service Administration at The University of Chicago, says the remaining states may feel more pressure to expand.

They are “getting pressure from hospitals and the business sector,” Grogan says. “It has an enormous impact on the economy. I don’t think any state is exempt from economic impact when they give up an infusion of federal funds.”

The federal government currently pays 100% of state Medicaid costs for the newly eligible upon expansion, eventually dropping to 90% by 2020.

A January 2016 Health Affairs study from researchers at Harvard University and Brigham and Women’s Hospital in Boston showed that traditional expansion in Kentucky and the “private option” expansion adopted in Arkansas both led to a decrease in the number of uninsured patients, an increase in access to healthcare, and fewer patients skipping medications or experiencing trouble paying medical bills between 2013 and expansion in 2014. This contrasted with the results in Texas, which has not expanded.3

Hospitalist Concerns

Patrick Cawley, MD, MBA, MHM, is CEO of the Medical University of South Carolina, previously practiced as a hospitalist, and is a past president of the Society of Hospital Medicine. For now, South Carolina is, like Texas, a non-expansion state. Dr. Cawley is concerned for the future of his hospital, an 800-bed academic, tertiary, safety-net hospital in Charleston, because payments to hospitals like his ultimately will drop.

 

Before a Supreme Court decision that ruled states were not compelled to expand Medicaid, the Affordable Care Act provided for a reduction in payments to safety-net hospitals. This was motivated by the notion that all hospitals would see a significant decrease in uncompensated care. The reduction has been delayed but is still scheduled to start in 2017.

“We couldn’t survive if disproportionate share goes away and something didn’t replace it, like Medicaid expansion,” Dr. Cawley says. But, he adds, over time he expects all or nearly all states will expand.

“When Medicaid first rolled out, it took 10 to 12 years before all states took it. I think expansion is the same way,” he says. “It’s one of those things that probably does work out, but what’s the transition going to be like, and how long is that transition going to last?” TH

---

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

References

1. Status of state action on the Medicaid expansion decision. Kaiser Family Foundation website. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Updated January 12, 2016. Accessed January 14, 2016.
2. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff. 2016;35(1):106-110. doi:10.1377/hlthaff.2015.1144.
3. Sommers BD, Blendon RJ, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff. 2016;35(1):96-105. doi:10.1377/hlthaff.2015.0917.
4. Jones CD, Scott SJ, Anoff DL, Pierce RG, Glasheen JJ. Changes in payer mix and physician reimbursement after the Affordable Care Act and Medicaid expansion. Inquiry. 2015;52. doi:10.1177/0046958015602464.

Presenter: Kyung E. Rhee, MD, MSc, MA

Summary: Eating disorders (ED) are common and have significant morbidity and mortality. EDs are the third most common psychiatric disorder of adolescents with a prevalence of 0.5-2% for anorexia and 0.9-3% for bulimia; 90% of patients are female. Mortality rate can be as high as 10% for anorexia and 1% for bulimia. Diagnosis is formally guided by DSM 5 criteria, but the mnemonic SCOFF can be useful:

1. Do you feel or make yourself SICK when eating?
2. Do you feel you’ve lost CONTROL of your eating?
3. Have you lost one STONE (14 lbs. developed by the British) of weight?
4. Do you feel FAT?
5. Does FOOD dominate your life?

A detailed history is needed as patients with ED may engage in secretive behaviors to hide their illness. After diagnosis, treatment may be outpatient or inpatient. Medical issues hospitalists are likely to see with inpatients include re-feeding syndrome, various metabolic disturbances, secondary amenorrhea, sleep disturbances, and for patients with bulimia, evidence of dental or esophageal trauma from purging. Differential diagnoses include: IBD, thyroid disease, celiac, diabetes, and Addison’s disease.

Hospitalists’ role in treatment is as part of a multidisciplinary group to manage the medical complications. Inpatient management includes individual and group therapy, monitored group meals, daily blind weights, bathroom visits, and focused lab studies. There is no “cure” and only ~50% of patients are free of ongoing symptoms after treatment.

Key Takeaways

• Eating disorders are common in adolescent females and have significant morbidity and mortality.
• Hospitalists’ role is diagnosis via careful history and management of medical complications with an eating disorder team. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Kyung E. Rhee, MD, MSc, MA

Summary: Eating disorders (ED) are common and have significant morbidity and mortality. EDs are the third most common psychiatric disorder of adolescents with a prevalence of 0.5-2% for anorexia and 0.9-3% for bulimia; 90% of patients are female. Mortality rate can be as high as 10% for anorexia and 1% for bulimia. Diagnosis is formally guided by DSM 5 criteria, but the mnemonic SCOFF can be useful:

1. Do you feel or make yourself SICK when eating?
2. Do you feel you’ve lost CONTROL of your eating?
3. Have you lost one STONE (14 lbs. developed by the British) of weight?
4. Do you feel FAT?
5. Does FOOD dominate your life?

A detailed history is needed as patients with ED may engage in secretive behaviors to hide their illness. After diagnosis, treatment may be outpatient or inpatient. Medical issues hospitalists are likely to see with inpatients include re-feeding syndrome, various metabolic disturbances, secondary amenorrhea, sleep disturbances, and for patients with bulimia, evidence of dental or esophageal trauma from purging. Differential diagnoses include: IBD, thyroid disease, celiac, diabetes, and Addison’s disease.

Hospitalists’ role in treatment is as part of a multidisciplinary group to manage the medical complications. Inpatient management includes individual and group therapy, monitored group meals, daily blind weights, bathroom visits, and focused lab studies. There is no “cure” and only ~50% of patients are free of ongoing symptoms after treatment.

Key Takeaways

• Eating disorders are common in adolescent females and have significant morbidity and mortality.
• Hospitalists’ role is diagnosis via careful history and management of medical complications with an eating disorder team. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Kyung E. Rhee, MD, MSc, MA

Summary: Eating disorders (ED) are common and have significant morbidity and mortality. EDs are the third most common psychiatric disorder of adolescents with a prevalence of 0.5-2% for anorexia and 0.9-3% for bulimia; 90% of patients are female. Mortality rate can be as high as 10% for anorexia and 1% for bulimia. Diagnosis is formally guided by DSM 5 criteria, but the mnemonic SCOFF can be useful:

1. Do you feel or make yourself SICK when eating?
2. Do you feel you’ve lost CONTROL of your eating?
3. Have you lost one STONE (14 lbs. developed by the British) of weight?
4. Do you feel FAT?
5. Does FOOD dominate your life?

A detailed history is needed as patients with ED may engage in secretive behaviors to hide their illness. After diagnosis, treatment may be outpatient or inpatient. Medical issues hospitalists are likely to see with inpatients include re-feeding syndrome, various metabolic disturbances, secondary amenorrhea, sleep disturbances, and for patients with bulimia, evidence of dental or esophageal trauma from purging. Differential diagnoses include: IBD, thyroid disease, celiac, diabetes, and Addison’s disease.

Hospitalists’ role in treatment is as part of a multidisciplinary group to manage the medical complications. Inpatient management includes individual and group therapy, monitored group meals, daily blind weights, bathroom visits, and focused lab studies. There is no “cure” and only ~50% of patients are free of ongoing symptoms after treatment.

Key Takeaways

• Eating disorders are common in adolescent females and have significant morbidity and mortality.
• Hospitalists’ role is diagnosis via careful history and management of medical complications with an eating disorder team. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.