ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness,  Brigham and Women’s Hospital, Boston.*

“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”

The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.

But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.

And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).

“There’s definitely a leaky pipeline here,” Dr. Harry said.

She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).

In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).

Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.

During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.

One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.

“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”

Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.

ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness,  Brigham and Women’s Hospital, Boston.*

“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”

The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.

But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.

And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).

“There’s definitely a leaky pipeline here,” Dr. Harry said.

She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).

In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).

Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.

During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.

One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.

“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”

Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.

ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness,  Brigham and Women’s Hospital, Boston.*

“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”

The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.

But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.

And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).

“There’s definitely a leaky pipeline here,” Dr. Harry said.

She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).

In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).

Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.

During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.

One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.

“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”

Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.

JACKSONVILLE, FLA. – Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Hospitals’ efforts to reduce post-acute care spending must focus on preventing complications. “Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform,” Dr. Kanters noted

Session moderator Courtney Balentine, MD, of the University of Alabama at Birmingham, asked Dr. Kanters whether the research considered the incentives hospital systems have for referring patients to their own post-acute care facilities. “Post-acute care association with a single hospital has been documented as a likely incentive for discharge to a non-home destination,” Dr. Kanters replied, which leads to higher utilization of “certain” post-acute care facilities and higher costs. However, she said, this study’s dataset could not parse out that trend. “That’s certainly something that needs to be investigated,” she said.

Dr. Kanters and her coauthors had no financial relationships to disclose.

Source: Kanters AE. Annual Academic Surgical Congress 2018.

JACKSONVILLE, FLA. – Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Hospitals’ efforts to reduce post-acute care spending must focus on preventing complications. “Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform,” Dr. Kanters noted

Session moderator Courtney Balentine, MD, of the University of Alabama at Birmingham, asked Dr. Kanters whether the research considered the incentives hospital systems have for referring patients to their own post-acute care facilities. “Post-acute care association with a single hospital has been documented as a likely incentive for discharge to a non-home destination,” Dr. Kanters replied, which leads to higher utilization of “certain” post-acute care facilities and higher costs. However, she said, this study’s dataset could not parse out that trend. “That’s certainly something that needs to be investigated,” she said.

Dr. Kanters and her coauthors had no financial relationships to disclose.

Source: Kanters AE. Annual Academic Surgical Congress 2018.

JACKSONVILLE, FLA. – Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Hospitals’ efforts to reduce post-acute care spending must focus on preventing complications. “Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform,” Dr. Kanters noted

Session moderator Courtney Balentine, MD, of the University of Alabama at Birmingham, asked Dr. Kanters whether the research considered the incentives hospital systems have for referring patients to their own post-acute care facilities. “Post-acute care association with a single hospital has been documented as a likely incentive for discharge to a non-home destination,” Dr. Kanters replied, which leads to higher utilization of “certain” post-acute care facilities and higher costs. However, she said, this study’s dataset could not parse out that trend. “That’s certainly something that needs to be investigated,” she said.

Dr. Kanters and her coauthors had no financial relationships to disclose.

Source: Kanters AE. Annual Academic Surgical Congress 2018.

A video-based intervention to promote parents reading aloud and playing with their child reduced hyperactivity at school entry and had sustained behavioral effects after the program was completed, according to results of a randomized clinical trial.

The Video Interaction Project (VIP), in which parents review and reflect upon recordings of themselves interacting with their children, is a low-cost, scalable intervention that has a “high potential” for enhancing social and emotional development by reducing disruptive behaviors, the study authors reported in Pediatrics.

Design Pics/Thinkstock

Those new strategies included building sessions around themes (such as birthday party), incorporation of writing into play (such as party invitations), focusing on story characters’ feelings, and video recording both reading and play, with the story serving as the basis for the play.

The initial VIP 0-3 year intervention and the VIP 3-5 year intervention were both independently associated with improved T-scores at 4.5 years on Behavior Assessment System for Children, Second Edition, rating scales, with Cohen’s d effect sizes ranging from approximately –0.25 to –0.30, according to investigators.

Participating in both VIP interventions was associated with a significant reduction in hyperactivity (effect size, –0.63; P = 0.001), Dr. Mendelsohn and his associates also reported.

Moreover, participation in the first VIP session was associated with a reduction in clinically significant hyperactivity (relative risk reduction, 69%; P = .03), they added.

The cost of the VIP program for 0-3 years is approximately $175-$200 per child per year, including staff, equipment, rent, and other expenses, according to the report, which notes that one interventionist can provide services for 400-500 families.

Taken together, these findings suggest the VIP intervention is a low-cost intervention that may prevent poverty-related disparities, investigators said.

“In this study, we provide strong support for the use of pediatric primary care to promote positive parenting activities such as reading aloud and play and the potential for such programs to promote social-emotional development as reflected through reductions in disruptive behaviors,” they wrote.

Dr. Mendelsohn and his coauthors reported no relevant financial disclosures. The study was supported by grants from the National Institutes of Health and the National Institute of Child Health and Human Development; the Tiger Foundation; the Marks Family Foundation; Children of Bellevue; KiDS of New York University Foundation; and Rhodebeck Charitable Trust. Several of the investigators were supported in part by awards or grants.

SOURCE: Mendelsohn AL et al. Pediatrics. 2018;141(5):e20173393.

A video-based intervention to promote parents reading aloud and playing with their child reduced hyperactivity at school entry and had sustained behavioral effects after the program was completed, according to results of a randomized clinical trial.

The Video Interaction Project (VIP), in which parents review and reflect upon recordings of themselves interacting with their children, is a low-cost, scalable intervention that has a “high potential” for enhancing social and emotional development by reducing disruptive behaviors, the study authors reported in Pediatrics.

Design Pics/Thinkstock

Those new strategies included building sessions around themes (such as birthday party), incorporation of writing into play (such as party invitations), focusing on story characters’ feelings, and video recording both reading and play, with the story serving as the basis for the play.

The initial VIP 0-3 year intervention and the VIP 3-5 year intervention were both independently associated with improved T-scores at 4.5 years on Behavior Assessment System for Children, Second Edition, rating scales, with Cohen’s d effect sizes ranging from approximately –0.25 to –0.30, according to investigators.

Participating in both VIP interventions was associated with a significant reduction in hyperactivity (effect size, –0.63; P = 0.001), Dr. Mendelsohn and his associates also reported.

Moreover, participation in the first VIP session was associated with a reduction in clinically significant hyperactivity (relative risk reduction, 69%; P = .03), they added.

The cost of the VIP program for 0-3 years is approximately $175-$200 per child per year, including staff, equipment, rent, and other expenses, according to the report, which notes that one interventionist can provide services for 400-500 families.

Taken together, these findings suggest the VIP intervention is a low-cost intervention that may prevent poverty-related disparities, investigators said.

“In this study, we provide strong support for the use of pediatric primary care to promote positive parenting activities such as reading aloud and play and the potential for such programs to promote social-emotional development as reflected through reductions in disruptive behaviors,” they wrote.

Dr. Mendelsohn and his coauthors reported no relevant financial disclosures. The study was supported by grants from the National Institutes of Health and the National Institute of Child Health and Human Development; the Tiger Foundation; the Marks Family Foundation; Children of Bellevue; KiDS of New York University Foundation; and Rhodebeck Charitable Trust. Several of the investigators were supported in part by awards or grants.

SOURCE: Mendelsohn AL et al. Pediatrics. 2018;141(5):e20173393.

A video-based intervention to promote parents reading aloud and playing with their child reduced hyperactivity at school entry and had sustained behavioral effects after the program was completed, according to results of a randomized clinical trial.

The Video Interaction Project (VIP), in which parents review and reflect upon recordings of themselves interacting with their children, is a low-cost, scalable intervention that has a “high potential” for enhancing social and emotional development by reducing disruptive behaviors, the study authors reported in Pediatrics.

Design Pics/Thinkstock

Those new strategies included building sessions around themes (such as birthday party), incorporation of writing into play (such as party invitations), focusing on story characters’ feelings, and video recording both reading and play, with the story serving as the basis for the play.

The initial VIP 0-3 year intervention and the VIP 3-5 year intervention were both independently associated with improved T-scores at 4.5 years on Behavior Assessment System for Children, Second Edition, rating scales, with Cohen’s d effect sizes ranging from approximately –0.25 to –0.30, according to investigators.

Participating in both VIP interventions was associated with a significant reduction in hyperactivity (effect size, –0.63; P = 0.001), Dr. Mendelsohn and his associates also reported.

Moreover, participation in the first VIP session was associated with a reduction in clinically significant hyperactivity (relative risk reduction, 69%; P = .03), they added.

The cost of the VIP program for 0-3 years is approximately $175-$200 per child per year, including staff, equipment, rent, and other expenses, according to the report, which notes that one interventionist can provide services for 400-500 families.

Taken together, these findings suggest the VIP intervention is a low-cost intervention that may prevent poverty-related disparities, investigators said.

“In this study, we provide strong support for the use of pediatric primary care to promote positive parenting activities such as reading aloud and play and the potential for such programs to promote social-emotional development as reflected through reductions in disruptive behaviors,” they wrote.

Dr. Mendelsohn and his coauthors reported no relevant financial disclosures. The study was supported by grants from the National Institutes of Health and the National Institute of Child Health and Human Development; the Tiger Foundation; the Marks Family Foundation; Children of Bellevue; KiDS of New York University Foundation; and Rhodebeck Charitable Trust. Several of the investigators were supported in part by awards or grants.

SOURCE: Mendelsohn AL et al. Pediatrics. 2018;141(5):e20173393.

WASHINGTON – Prior authorization, clinical decision support, provider education, altered cost sharing, and evidence review can and should be employed to reduce the volume of low-value services paid for by Medicare, according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.

At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.

Gregory Twachtman/MDedge News

Gregory Twachtman/MDedge News

Paul Ginsburg, PhD, commissioner and senior fellow in economic studies at the Brookings Institution, Washington, suggested that, for any new procedure or drug, initial coverage is always provisional for a certain length of time, which would force CMS to revisit coverage decisions.

“If there is no evidence, the coverage ends,” Dr Ginsburg said. “If there is positive evidence, the coverage proceeds.”

However, as commissioner Rita Redberg, MD, of the University of California, San Francisco, said of CMS, even with tools to cut coverage, its hands may be tied by outside forces. “CMS needs a lot more political cover.”

Gregory Twachtman/MDedge News

Dr. Redberg noted that there was extensive lobbying of local carriers, and within 6 months, despite the lack of evidence, everyone was covering cardiac CT.

“A few years later, CMS tried to walk back the coverage because it was just hemorrhaging money for cardiac CT, but there was no chance because it was a capital investment,” she added. “Even when there are restrictions on coverage, CMS doesn’t enforce them.”

Ms. Buto also raised the issue of how much influence CMS has over Medicare Part D prescription drug plan sponsors’ coverage decision policies, but suggested CMS could play a larger role in that.

Commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, suggested that, “We need to do more from a Part D perspective to allow plans to manage drug coverage more aggressively and in line with the commercial space. CMS has handcuffed them,” noting that FDA approval, regardless of value, generally means Medicare coverage.

Commissioner Jack Hoadley, PhD, of Georgetown University in Washington, cautioned that any discussion on these or possibly other tools needs to take into account the needs of those who will legitimately benefit from some of the low-value services so they do not inadvertently prevent access for those patients.

At press time, MedPAC had not scheduled a vote on specific recommendations to address low-value care.

[email protected]

WASHINGTON – Prior authorization, clinical decision support, provider education, altered cost sharing, and evidence review can and should be employed to reduce the volume of low-value services paid for by Medicare, according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.

At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.

Gregory Twachtman/MDedge News

Gregory Twachtman/MDedge News

Paul Ginsburg, PhD, commissioner and senior fellow in economic studies at the Brookings Institution, Washington, suggested that, for any new procedure or drug, initial coverage is always provisional for a certain length of time, which would force CMS to revisit coverage decisions.

“If there is no evidence, the coverage ends,” Dr Ginsburg said. “If there is positive evidence, the coverage proceeds.”

However, as commissioner Rita Redberg, MD, of the University of California, San Francisco, said of CMS, even with tools to cut coverage, its hands may be tied by outside forces. “CMS needs a lot more political cover.”

Gregory Twachtman/MDedge News

Dr. Redberg noted that there was extensive lobbying of local carriers, and within 6 months, despite the lack of evidence, everyone was covering cardiac CT.

“A few years later, CMS tried to walk back the coverage because it was just hemorrhaging money for cardiac CT, but there was no chance because it was a capital investment,” she added. “Even when there are restrictions on coverage, CMS doesn’t enforce them.”

Ms. Buto also raised the issue of how much influence CMS has over Medicare Part D prescription drug plan sponsors’ coverage decision policies, but suggested CMS could play a larger role in that.

Commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, suggested that, “We need to do more from a Part D perspective to allow plans to manage drug coverage more aggressively and in line with the commercial space. CMS has handcuffed them,” noting that FDA approval, regardless of value, generally means Medicare coverage.

Commissioner Jack Hoadley, PhD, of Georgetown University in Washington, cautioned that any discussion on these or possibly other tools needs to take into account the needs of those who will legitimately benefit from some of the low-value services so they do not inadvertently prevent access for those patients.

At press time, MedPAC had not scheduled a vote on specific recommendations to address low-value care.

[email protected]

WASHINGTON – Prior authorization, clinical decision support, provider education, altered cost sharing, and evidence review can and should be employed to reduce the volume of low-value services paid for by Medicare, according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.

At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.

Gregory Twachtman/MDedge News

Gregory Twachtman/MDedge News

Paul Ginsburg, PhD, commissioner and senior fellow in economic studies at the Brookings Institution, Washington, suggested that, for any new procedure or drug, initial coverage is always provisional for a certain length of time, which would force CMS to revisit coverage decisions.

“If there is no evidence, the coverage ends,” Dr Ginsburg said. “If there is positive evidence, the coverage proceeds.”

However, as commissioner Rita Redberg, MD, of the University of California, San Francisco, said of CMS, even with tools to cut coverage, its hands may be tied by outside forces. “CMS needs a lot more political cover.”

Gregory Twachtman/MDedge News

Dr. Redberg noted that there was extensive lobbying of local carriers, and within 6 months, despite the lack of evidence, everyone was covering cardiac CT.

“A few years later, CMS tried to walk back the coverage because it was just hemorrhaging money for cardiac CT, but there was no chance because it was a capital investment,” she added. “Even when there are restrictions on coverage, CMS doesn’t enforce them.”

Ms. Buto also raised the issue of how much influence CMS has over Medicare Part D prescription drug plan sponsors’ coverage decision policies, but suggested CMS could play a larger role in that.

Commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, suggested that, “We need to do more from a Part D perspective to allow plans to manage drug coverage more aggressively and in line with the commercial space. CMS has handcuffed them,” noting that FDA approval, regardless of value, generally means Medicare coverage.

Commissioner Jack Hoadley, PhD, of Georgetown University in Washington, cautioned that any discussion on these or possibly other tools needs to take into account the needs of those who will legitimately benefit from some of the low-value services so they do not inadvertently prevent access for those patients.

At press time, MedPAC had not scheduled a vote on specific recommendations to address low-value care.

[email protected]

CHICAGO – As Medicare transitions to a value-based model that uses bundled payments, oncologic surgeons and medical institutions may want to take a close look at enhanced recovery pathways and more minimally invasive surgery for colectomy in both benign and malignant disease to close potential gaps in reimbursement and outcomes, according to a retrospective study of 4-year Medicare data presented at the Society of Surgical Oncology Annual Cancer Symposium here.

• DRG poorly differentiates between benign and malignant disease. This problem is evidenced by the higher cost for the index admission in benign disease. “Whereas in malignant disease, there is a greater unrecognized cost-shifting to post-acute care services which are not addressed by the DRG system,” he said.
• The dominance of open colectomy where MIS could reduce episode costs. The study cited research that reported the advantages of MIS include lower episode costs in both younger and older patients, by $1,466 and $632, respectively; shorter hospital stays by 1.46 days; 20% lower 30-day readmissions rates; and lower rates of post-acute care services (J Laparoendosc Adv Surg Tech A. 2017 Dec 13. doi: 10.1089/lap.2017.0521)
• Potential for DRG migration from code 331 (benign disease) to 330 (colon cancer but not with metastasis). Dr. Hughes and his coauthors published a study that reported a 14.2% rate of DRG migration in this same Medicare cohort, that is, classified as 331 on admission but migrated to 330. So, compared with other patients, this group ended up with longer LOS (7.6 vs. 4.8 days); higher total charges ($63,149 vs. $46,339); and higher CMS payment ($11,159 vs. $7,210) (Am J Surg. 2018;215:493-6). “We also identified a potential role for enhanced-recovery pathways to mitigate these factors,” he said.

He noted that the different stakeholders – hospitals, surgeons, anesthesiologists, hospitalists, other physicians, nurses, and extenders – will have to resolve how to divide bundled payments. “The biggest thing is communication between these groups, because moving forward CMS is trying to step away from the role of determining who gets paid what,” Dr. Hughes said. He noted this finding is consistent with his own previously published findings, along with those from senior study coauthor Anthony J. Senagore, MD, FACS, on resource consumption in value-based care.

Dr. Hughes and coauthors reported having no financial disclosures. Dr. Hughes is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

SOURCE: Huges BD. SSO 2018.

CHICAGO – As Medicare transitions to a value-based model that uses bundled payments, oncologic surgeons and medical institutions may want to take a close look at enhanced recovery pathways and more minimally invasive surgery for colectomy in both benign and malignant disease to close potential gaps in reimbursement and outcomes, according to a retrospective study of 4-year Medicare data presented at the Society of Surgical Oncology Annual Cancer Symposium here.

• DRG poorly differentiates between benign and malignant disease. This problem is evidenced by the higher cost for the index admission in benign disease. “Whereas in malignant disease, there is a greater unrecognized cost-shifting to post-acute care services which are not addressed by the DRG system,” he said.
• The dominance of open colectomy where MIS could reduce episode costs. The study cited research that reported the advantages of MIS include lower episode costs in both younger and older patients, by $1,466 and $632, respectively; shorter hospital stays by 1.46 days; 20% lower 30-day readmissions rates; and lower rates of post-acute care services (J Laparoendosc Adv Surg Tech A. 2017 Dec 13. doi: 10.1089/lap.2017.0521)
• Potential for DRG migration from code 331 (benign disease) to 330 (colon cancer but not with metastasis). Dr. Hughes and his coauthors published a study that reported a 14.2% rate of DRG migration in this same Medicare cohort, that is, classified as 331 on admission but migrated to 330. So, compared with other patients, this group ended up with longer LOS (7.6 vs. 4.8 days); higher total charges ($63,149 vs. $46,339); and higher CMS payment ($11,159 vs. $7,210) (Am J Surg. 2018;215:493-6). “We also identified a potential role for enhanced-recovery pathways to mitigate these factors,” he said.

He noted that the different stakeholders – hospitals, surgeons, anesthesiologists, hospitalists, other physicians, nurses, and extenders – will have to resolve how to divide bundled payments. “The biggest thing is communication between these groups, because moving forward CMS is trying to step away from the role of determining who gets paid what,” Dr. Hughes said. He noted this finding is consistent with his own previously published findings, along with those from senior study coauthor Anthony J. Senagore, MD, FACS, on resource consumption in value-based care.

Dr. Hughes and coauthors reported having no financial disclosures. Dr. Hughes is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

SOURCE: Huges BD. SSO 2018.

CHICAGO – As Medicare transitions to a value-based model that uses bundled payments, oncologic surgeons and medical institutions may want to take a close look at enhanced recovery pathways and more minimally invasive surgery for colectomy in both benign and malignant disease to close potential gaps in reimbursement and outcomes, according to a retrospective study of 4-year Medicare data presented at the Society of Surgical Oncology Annual Cancer Symposium here.

• DRG poorly differentiates between benign and malignant disease. This problem is evidenced by the higher cost for the index admission in benign disease. “Whereas in malignant disease, there is a greater unrecognized cost-shifting to post-acute care services which are not addressed by the DRG system,” he said.
• The dominance of open colectomy where MIS could reduce episode costs. The study cited research that reported the advantages of MIS include lower episode costs in both younger and older patients, by $1,466 and $632, respectively; shorter hospital stays by 1.46 days; 20% lower 30-day readmissions rates; and lower rates of post-acute care services (J Laparoendosc Adv Surg Tech A. 2017 Dec 13. doi: 10.1089/lap.2017.0521)
• Potential for DRG migration from code 331 (benign disease) to 330 (colon cancer but not with metastasis). Dr. Hughes and his coauthors published a study that reported a 14.2% rate of DRG migration in this same Medicare cohort, that is, classified as 331 on admission but migrated to 330. So, compared with other patients, this group ended up with longer LOS (7.6 vs. 4.8 days); higher total charges ($63,149 vs. $46,339); and higher CMS payment ($11,159 vs. $7,210) (Am J Surg. 2018;215:493-6). “We also identified a potential role for enhanced-recovery pathways to mitigate these factors,” he said.

He noted that the different stakeholders – hospitals, surgeons, anesthesiologists, hospitalists, other physicians, nurses, and extenders – will have to resolve how to divide bundled payments. “The biggest thing is communication between these groups, because moving forward CMS is trying to step away from the role of determining who gets paid what,” Dr. Hughes said. He noted this finding is consistent with his own previously published findings, along with those from senior study coauthor Anthony J. Senagore, MD, FACS, on resource consumption in value-based care.

Dr. Hughes and coauthors reported having no financial disclosures. Dr. Hughes is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

SOURCE: Huges BD. SSO 2018.

ORLANDO – Hospitalists in attendance at a Rapid Fire session at the Society of Hospital Medicine’s annual conference came away with updated information about stroke and intracranial hemorrhage, among the neurologic emergencies commonly seen in hospitalized patients.

Aaron Lord, MD, chief of neurocritical care at New York University Langone Health, provided hopeful news about thrombectomy for ischemic stroke and confirmed the importance of blood pressure management in intracranial hemorrhage in his review of several common neurologic emergencies.

Dr. Lord said that, for ischemic stroke, the evidence is now very good for mechanical thrombectomy, with newer data pointing to a prolonged treatment window for some patients.

Though IV tissue plasminogen activator (TPA) is the only Food and Drug Administration–approved pharmacologic treatment for acute stroke, said Dr. Lord, “It’s good, but it’s not perfect. It doesn’t necessarily target the clot or concentrate in it. ... The big kicker is that not all patients are candidates for IV TPA. They either present too late or have comorbidities.”

“Frustratingly, even for those who do present on time, TPA doesn’t work for everyone. This is especially true for large or long clots,” said Dr. Lord. In 2015, he said, a half-dozen trials examining mechanical thrombectomy for acute stroke were all positive, giving assurance to physicians and patients of this therapy’s efficacy within the 6-8 hour acute stroke window. Pooled analysis of the 2015 trials showed a number needed to treat (NNT) of 5 for regaining functional independence, and a NNT of 2.6 for decreased disability.

Further, he said, two additional trials have examined thrombectomy’s utility when patients have a large stroke penumbra, with a relatively small core infarct, using “tissue-based parameters rather than time” to select patients for thrombectomy. “These trials were just as positive as the initial trials,” said Dr. Lord; the trials showed NNTs of 2.9 and 3.6 for reduced disability in a population of patients who were 6-24 hours poststroke.

The takeaway for hospitalists? Even when it’s unknown how much time has passed since the onset of stroke symptoms, step No. 1 is still to activate the stroke team’s resources, giving patients the best hope for recovery. “We now have the luxury of treating patients up to 24 hours. This has revolutionized the way that we treat acute stroke,” said Dr. Lord.

For intracranial hemorrhage, the story is a little different. Here, “initial management focuses on preventing hematoma expansion,” said Dr. Lord.

After tending to airway, breathing, and circulation and activation of the stroke team, the managing clinician should turn to blood pressure management and reversal of any anticoagulation or antiplatelet therapy.

The medical literature gives some guidance about goal blood pressures, he said. Although all of the trials did not use the same parameters for “highest” or “lower” systolic blood pressures, the best data available point toward a systolic goal of about 140.

“Blood pressure treatment is still important,” said Dr. Lord. In larger hemorrhages or with hydrocephalus, he advised always at least considering placement of an intracranial pressure monitor.

If a patient is anticoagulated with a vitamin K antagonist, he said, the INCH trial showed that intracranial bleeds are best reversed by use of prothrombin complex concentration (PCC), rather than fresh frozen plasma (FFP). The trial, stopped early for safety, showed that the primary outcome of internationalized normal ratio of less than 1.2 by the 3-hour mark was reached by just 9% of the FFP group, compared with 67% of those who received PCC. Mortality was 35% for the FFP cohort, compared with 19% who received PCC.

Dr. Lord finds these data compelling. “When I ask my residents what the appropriate agent is for vitamin K reversal in acute ICH, and they answer FFP, I tell them, ‘That’s a great answer ... for 2012.’ ”

ORLANDO – Hospitalists in attendance at a Rapid Fire session at the Society of Hospital Medicine’s annual conference came away with updated information about stroke and intracranial hemorrhage, among the neurologic emergencies commonly seen in hospitalized patients.

Aaron Lord, MD, chief of neurocritical care at New York University Langone Health, provided hopeful news about thrombectomy for ischemic stroke and confirmed the importance of blood pressure management in intracranial hemorrhage in his review of several common neurologic emergencies.

Dr. Lord said that, for ischemic stroke, the evidence is now very good for mechanical thrombectomy, with newer data pointing to a prolonged treatment window for some patients.

Though IV tissue plasminogen activator (TPA) is the only Food and Drug Administration–approved pharmacologic treatment for acute stroke, said Dr. Lord, “It’s good, but it’s not perfect. It doesn’t necessarily target the clot or concentrate in it. ... The big kicker is that not all patients are candidates for IV TPA. They either present too late or have comorbidities.”

“Frustratingly, even for those who do present on time, TPA doesn’t work for everyone. This is especially true for large or long clots,” said Dr. Lord. In 2015, he said, a half-dozen trials examining mechanical thrombectomy for acute stroke were all positive, giving assurance to physicians and patients of this therapy’s efficacy within the 6-8 hour acute stroke window. Pooled analysis of the 2015 trials showed a number needed to treat (NNT) of 5 for regaining functional independence, and a NNT of 2.6 for decreased disability.

Further, he said, two additional trials have examined thrombectomy’s utility when patients have a large stroke penumbra, with a relatively small core infarct, using “tissue-based parameters rather than time” to select patients for thrombectomy. “These trials were just as positive as the initial trials,” said Dr. Lord; the trials showed NNTs of 2.9 and 3.6 for reduced disability in a population of patients who were 6-24 hours poststroke.

The takeaway for hospitalists? Even when it’s unknown how much time has passed since the onset of stroke symptoms, step No. 1 is still to activate the stroke team’s resources, giving patients the best hope for recovery. “We now have the luxury of treating patients up to 24 hours. This has revolutionized the way that we treat acute stroke,” said Dr. Lord.

For intracranial hemorrhage, the story is a little different. Here, “initial management focuses on preventing hematoma expansion,” said Dr. Lord.

After tending to airway, breathing, and circulation and activation of the stroke team, the managing clinician should turn to blood pressure management and reversal of any anticoagulation or antiplatelet therapy.

The medical literature gives some guidance about goal blood pressures, he said. Although all of the trials did not use the same parameters for “highest” or “lower” systolic blood pressures, the best data available point toward a systolic goal of about 140.

“Blood pressure treatment is still important,” said Dr. Lord. In larger hemorrhages or with hydrocephalus, he advised always at least considering placement of an intracranial pressure monitor.

If a patient is anticoagulated with a vitamin K antagonist, he said, the INCH trial showed that intracranial bleeds are best reversed by use of prothrombin complex concentration (PCC), rather than fresh frozen plasma (FFP). The trial, stopped early for safety, showed that the primary outcome of internationalized normal ratio of less than 1.2 by the 3-hour mark was reached by just 9% of the FFP group, compared with 67% of those who received PCC. Mortality was 35% for the FFP cohort, compared with 19% who received PCC.

Dr. Lord finds these data compelling. “When I ask my residents what the appropriate agent is for vitamin K reversal in acute ICH, and they answer FFP, I tell them, ‘That’s a great answer ... for 2012.’ ”

ORLANDO – Hospitalists in attendance at a Rapid Fire session at the Society of Hospital Medicine’s annual conference came away with updated information about stroke and intracranial hemorrhage, among the neurologic emergencies commonly seen in hospitalized patients.

Aaron Lord, MD, chief of neurocritical care at New York University Langone Health, provided hopeful news about thrombectomy for ischemic stroke and confirmed the importance of blood pressure management in intracranial hemorrhage in his review of several common neurologic emergencies.

Dr. Lord said that, for ischemic stroke, the evidence is now very good for mechanical thrombectomy, with newer data pointing to a prolonged treatment window for some patients.

Though IV tissue plasminogen activator (TPA) is the only Food and Drug Administration–approved pharmacologic treatment for acute stroke, said Dr. Lord, “It’s good, but it’s not perfect. It doesn’t necessarily target the clot or concentrate in it. ... The big kicker is that not all patients are candidates for IV TPA. They either present too late or have comorbidities.”

“Frustratingly, even for those who do present on time, TPA doesn’t work for everyone. This is especially true for large or long clots,” said Dr. Lord. In 2015, he said, a half-dozen trials examining mechanical thrombectomy for acute stroke were all positive, giving assurance to physicians and patients of this therapy’s efficacy within the 6-8 hour acute stroke window. Pooled analysis of the 2015 trials showed a number needed to treat (NNT) of 5 for regaining functional independence, and a NNT of 2.6 for decreased disability.

Further, he said, two additional trials have examined thrombectomy’s utility when patients have a large stroke penumbra, with a relatively small core infarct, using “tissue-based parameters rather than time” to select patients for thrombectomy. “These trials were just as positive as the initial trials,” said Dr. Lord; the trials showed NNTs of 2.9 and 3.6 for reduced disability in a population of patients who were 6-24 hours poststroke.

The takeaway for hospitalists? Even when it’s unknown how much time has passed since the onset of stroke symptoms, step No. 1 is still to activate the stroke team’s resources, giving patients the best hope for recovery. “We now have the luxury of treating patients up to 24 hours. This has revolutionized the way that we treat acute stroke,” said Dr. Lord.

For intracranial hemorrhage, the story is a little different. Here, “initial management focuses on preventing hematoma expansion,” said Dr. Lord.

After tending to airway, breathing, and circulation and activation of the stroke team, the managing clinician should turn to blood pressure management and reversal of any anticoagulation or antiplatelet therapy.

The medical literature gives some guidance about goal blood pressures, he said. Although all of the trials did not use the same parameters for “highest” or “lower” systolic blood pressures, the best data available point toward a systolic goal of about 140.

“Blood pressure treatment is still important,” said Dr. Lord. In larger hemorrhages or with hydrocephalus, he advised always at least considering placement of an intracranial pressure monitor.

If a patient is anticoagulated with a vitamin K antagonist, he said, the INCH trial showed that intracranial bleeds are best reversed by use of prothrombin complex concentration (PCC), rather than fresh frozen plasma (FFP). The trial, stopped early for safety, showed that the primary outcome of internationalized normal ratio of less than 1.2 by the 3-hour mark was reached by just 9% of the FFP group, compared with 67% of those who received PCC. Mortality was 35% for the FFP cohort, compared with 19% who received PCC.

Dr. Lord finds these data compelling. “When I ask my residents what the appropriate agent is for vitamin K reversal in acute ICH, and they answer FFP, I tell them, ‘That’s a great answer ... for 2012.’ ”

ORLANDO – The top award in the research arm of the Research, Innovations and Clinical Vignettes (RIV) competition, bestowed Monday night at HM18, went to investigators at Brigham and Women’s Hospital in Boston, who looked for trouble spots in interhospital transfers across more than 24,000 cases.

In the innovations category, also awarded Tuesday night, the top award went to clinicians and researchers at the University of Iowa in Iowa City, who attempted to use “virtual hospitalists” to improve local care at rural, critical-access hospitals.

The winning study in the research arm set out to pinpoint problems that could be attributed to process in cases of patients being transferred from one acute care facility to another, and was presented by Stephanie Mueller, MD, MPH, SFHM, associate physician in the hospital medicine unit at Brigham and Women’s.

Dr. Mueller and her colleagues looked at transfers to the hospital from 2005 to 2013. They analyzed the effects that three factors – day of the week, time of day, and admission team “busyness” on the day of the transfer – had on transfers to intensive care within 48 hours and on 30-day mortality. They looked at data for Monday through Thursday, compared with Friday through Sunday, at day, evening, and night transfers as well as the number of patient admissions and discharges to the admitting team on that day.

They found that nighttime arrival was linked with an increased chance of being transferred to the ICU and with 30-day mortality. They also found that weekday arrival was associated with lower odds of mortality among patients getting cardiothoracic and gastrointestinal surgery.

“I think that these are potential targets in which we can actually do something to mitigate the outcomes for these patients,” Dr. Mueller said. “I’m working on a number of studies related to this topic and so it’s sort of validating that this is an important topic and that I should continue doing what I’m doing.”

Raj Sehgal, MD, FHM, a judge in the research arm and associate professor at University of Texas, San Antonio, praised the relevance of the project.

“Interhospital transfer is a topic that a lot of hospitals are dealing with right now,” he said. “It’s always a group of patients that we worry about.”

“One of the strongest things about this poster was the strong methodology,” said another judge, Vineet Gupta, MD, FHM, assistant clinical professor at the University of California, San Diego. “The statistical analysis was really good, very strong, very robust.”

The innovations award–winning study, presented by Ethan Kuperman, MD, MSc, FHM, clinical assistant professor at the University of Iowa, involved an attempt to reduce transfers from the emergency departments of critical-access hospitals in rural Iowa to urban medical centers by providing care with “virtual hospitalists” using tablets.

“Our goal was to treat more patients locally, to keep those patients happy in their communities. That’s what patients get out of it,” Dr. Kuperman told judges. “The hospitals get to keep their family practice doctors doing primary care, stay open, and get more patients. Win, win, win.”

At the critical-access hospital pilot site, virtual hospitalists at the University of Iowa handled all inpatient and observation admissions, with the assistance of local advance practice professionals. The percentage of outside transfers from the emergency department over 64 weeks after implementation was 12.9%, a statistically significant drop from the 16.6% seen in a 24-week baseline period. This did not lead to another goal – a higher daily census at the hospital – though, because there was also a drop in ED visits that ended in a hospital admission.

At two other sites, where virtual hospitalists provided fewer services – at one site, they also helped with preoperative work – there was less of an impact, Dr. Kuperman said. He said he was encouraged that the mean time reported by virtual hospitalists for patient care and documentation was just 2.8 hours a day, but there were days when that hit 12 hours, so there could be a need for “surge” coverage.

He said he’s gratified that the award draws more attention to attempts to improve the care at rural hospitals and that he plans to continue to develop the program.

“Hopefully, this helps get the word out,” Dr. Kuperman said. “I think a lot of work still needs to be done.”

The awards capped a 2-hour competition in which judges went from poster to poster, hearing short presentations from researchers and asking rapid-fire questions. The decisions were difficult in both categories, the judges said. The judges in the innovations category, for instance, deliberated at a table outside the exhibit hall for about 20 minutes before coming to a decision.

The pool of 20 finalists – 10 in each category – were chosen from hundreds of submissions considered during the final two rounds of judging on Tuesday night. In the research category, 261 abstracts were accepted from the 319 submitted; in the innovations category, 140 were accepted from the 207 submitted.

ORLANDO – The top award in the research arm of the Research, Innovations and Clinical Vignettes (RIV) competition, bestowed Monday night at HM18, went to investigators at Brigham and Women’s Hospital in Boston, who looked for trouble spots in interhospital transfers across more than 24,000 cases.

In the innovations category, also awarded Tuesday night, the top award went to clinicians and researchers at the University of Iowa in Iowa City, who attempted to use “virtual hospitalists” to improve local care at rural, critical-access hospitals.

The winning study in the research arm set out to pinpoint problems that could be attributed to process in cases of patients being transferred from one acute care facility to another, and was presented by Stephanie Mueller, MD, MPH, SFHM, associate physician in the hospital medicine unit at Brigham and Women’s.

Dr. Mueller and her colleagues looked at transfers to the hospital from 2005 to 2013. They analyzed the effects that three factors – day of the week, time of day, and admission team “busyness” on the day of the transfer – had on transfers to intensive care within 48 hours and on 30-day mortality. They looked at data for Monday through Thursday, compared with Friday through Sunday, at day, evening, and night transfers as well as the number of patient admissions and discharges to the admitting team on that day.

They found that nighttime arrival was linked with an increased chance of being transferred to the ICU and with 30-day mortality. They also found that weekday arrival was associated with lower odds of mortality among patients getting cardiothoracic and gastrointestinal surgery.

“I think that these are potential targets in which we can actually do something to mitigate the outcomes for these patients,” Dr. Mueller said. “I’m working on a number of studies related to this topic and so it’s sort of validating that this is an important topic and that I should continue doing what I’m doing.”

Raj Sehgal, MD, FHM, a judge in the research arm and associate professor at University of Texas, San Antonio, praised the relevance of the project.

“Interhospital transfer is a topic that a lot of hospitals are dealing with right now,” he said. “It’s always a group of patients that we worry about.”

“One of the strongest things about this poster was the strong methodology,” said another judge, Vineet Gupta, MD, FHM, assistant clinical professor at the University of California, San Diego. “The statistical analysis was really good, very strong, very robust.”

The innovations award–winning study, presented by Ethan Kuperman, MD, MSc, FHM, clinical assistant professor at the University of Iowa, involved an attempt to reduce transfers from the emergency departments of critical-access hospitals in rural Iowa to urban medical centers by providing care with “virtual hospitalists” using tablets.

“Our goal was to treat more patients locally, to keep those patients happy in their communities. That’s what patients get out of it,” Dr. Kuperman told judges. “The hospitals get to keep their family practice doctors doing primary care, stay open, and get more patients. Win, win, win.”

At the critical-access hospital pilot site, virtual hospitalists at the University of Iowa handled all inpatient and observation admissions, with the assistance of local advance practice professionals. The percentage of outside transfers from the emergency department over 64 weeks after implementation was 12.9%, a statistically significant drop from the 16.6% seen in a 24-week baseline period. This did not lead to another goal – a higher daily census at the hospital – though, because there was also a drop in ED visits that ended in a hospital admission.

At two other sites, where virtual hospitalists provided fewer services – at one site, they also helped with preoperative work – there was less of an impact, Dr. Kuperman said. He said he was encouraged that the mean time reported by virtual hospitalists for patient care and documentation was just 2.8 hours a day, but there were days when that hit 12 hours, so there could be a need for “surge” coverage.

He said he’s gratified that the award draws more attention to attempts to improve the care at rural hospitals and that he plans to continue to develop the program.

“Hopefully, this helps get the word out,” Dr. Kuperman said. “I think a lot of work still needs to be done.”

The awards capped a 2-hour competition in which judges went from poster to poster, hearing short presentations from researchers and asking rapid-fire questions. The decisions were difficult in both categories, the judges said. The judges in the innovations category, for instance, deliberated at a table outside the exhibit hall for about 20 minutes before coming to a decision.

The pool of 20 finalists – 10 in each category – were chosen from hundreds of submissions considered during the final two rounds of judging on Tuesday night. In the research category, 261 abstracts were accepted from the 319 submitted; in the innovations category, 140 were accepted from the 207 submitted.

ORLANDO – The top award in the research arm of the Research, Innovations and Clinical Vignettes (RIV) competition, bestowed Monday night at HM18, went to investigators at Brigham and Women’s Hospital in Boston, who looked for trouble spots in interhospital transfers across more than 24,000 cases.

In the innovations category, also awarded Tuesday night, the top award went to clinicians and researchers at the University of Iowa in Iowa City, who attempted to use “virtual hospitalists” to improve local care at rural, critical-access hospitals.

The winning study in the research arm set out to pinpoint problems that could be attributed to process in cases of patients being transferred from one acute care facility to another, and was presented by Stephanie Mueller, MD, MPH, SFHM, associate physician in the hospital medicine unit at Brigham and Women’s.

Dr. Mueller and her colleagues looked at transfers to the hospital from 2005 to 2013. They analyzed the effects that three factors – day of the week, time of day, and admission team “busyness” on the day of the transfer – had on transfers to intensive care within 48 hours and on 30-day mortality. They looked at data for Monday through Thursday, compared with Friday through Sunday, at day, evening, and night transfers as well as the number of patient admissions and discharges to the admitting team on that day.

They found that nighttime arrival was linked with an increased chance of being transferred to the ICU and with 30-day mortality. They also found that weekday arrival was associated with lower odds of mortality among patients getting cardiothoracic and gastrointestinal surgery.

“I think that these are potential targets in which we can actually do something to mitigate the outcomes for these patients,” Dr. Mueller said. “I’m working on a number of studies related to this topic and so it’s sort of validating that this is an important topic and that I should continue doing what I’m doing.”

Raj Sehgal, MD, FHM, a judge in the research arm and associate professor at University of Texas, San Antonio, praised the relevance of the project.

“Interhospital transfer is a topic that a lot of hospitals are dealing with right now,” he said. “It’s always a group of patients that we worry about.”

“One of the strongest things about this poster was the strong methodology,” said another judge, Vineet Gupta, MD, FHM, assistant clinical professor at the University of California, San Diego. “The statistical analysis was really good, very strong, very robust.”

The innovations award–winning study, presented by Ethan Kuperman, MD, MSc, FHM, clinical assistant professor at the University of Iowa, involved an attempt to reduce transfers from the emergency departments of critical-access hospitals in rural Iowa to urban medical centers by providing care with “virtual hospitalists” using tablets.

“Our goal was to treat more patients locally, to keep those patients happy in their communities. That’s what patients get out of it,” Dr. Kuperman told judges. “The hospitals get to keep their family practice doctors doing primary care, stay open, and get more patients. Win, win, win.”

At the critical-access hospital pilot site, virtual hospitalists at the University of Iowa handled all inpatient and observation admissions, with the assistance of local advance practice professionals. The percentage of outside transfers from the emergency department over 64 weeks after implementation was 12.9%, a statistically significant drop from the 16.6% seen in a 24-week baseline period. This did not lead to another goal – a higher daily census at the hospital – though, because there was also a drop in ED visits that ended in a hospital admission.

At two other sites, where virtual hospitalists provided fewer services – at one site, they also helped with preoperative work – there was less of an impact, Dr. Kuperman said. He said he was encouraged that the mean time reported by virtual hospitalists for patient care and documentation was just 2.8 hours a day, but there were days when that hit 12 hours, so there could be a need for “surge” coverage.

He said he’s gratified that the award draws more attention to attempts to improve the care at rural hospitals and that he plans to continue to develop the program.

“Hopefully, this helps get the word out,” Dr. Kuperman said. “I think a lot of work still needs to be done.”

The awards capped a 2-hour competition in which judges went from poster to poster, hearing short presentations from researchers and asking rapid-fire questions. The decisions were difficult in both categories, the judges said. The judges in the innovations category, for instance, deliberated at a table outside the exhibit hall for about 20 minutes before coming to a decision.

The pool of 20 finalists – 10 in each category – were chosen from hundreds of submissions considered during the final two rounds of judging on Tuesday night. In the research category, 261 abstracts were accepted from the 319 submitted; in the innovations category, 140 were accepted from the 207 submitted.

ORLANDO – In a video interview, Brian Kwan, MD, SFHM, of the University of California, San Diego, discusses the role of the SHM Physicians in Training Committee in “increasing the hospitalist pipeline.”

In discussing the work of the committee, Dr. Kwan describes how “a lot of our initiatives really focus on the training and development and basically nurturing them from becoming students to residents to early-career hospitalists.”

Two of the key programs he discusses are the Student Scholarship Program and the “new-this-year” Resident Travel Grant, among other initiatives that the committee is exploring.

ORLANDO – In a video interview, Brian Kwan, MD, SFHM, of the University of California, San Diego, discusses the role of the SHM Physicians in Training Committee in “increasing the hospitalist pipeline.”

In discussing the work of the committee, Dr. Kwan describes how “a lot of our initiatives really focus on the training and development and basically nurturing them from becoming students to residents to early-career hospitalists.”

Two of the key programs he discusses are the Student Scholarship Program and the “new-this-year” Resident Travel Grant, among other initiatives that the committee is exploring.

ORLANDO – In a video interview, Brian Kwan, MD, SFHM, of the University of California, San Diego, discusses the role of the SHM Physicians in Training Committee in “increasing the hospitalist pipeline.”

In discussing the work of the committee, Dr. Kwan describes how “a lot of our initiatives really focus on the training and development and basically nurturing them from becoming students to residents to early-career hospitalists.”

Two of the key programs he discusses are the Student Scholarship Program and the “new-this-year” Resident Travel Grant, among other initiatives that the committee is exploring.

Workers in the health care and social assistance industry are more likely to have asthma than those in any other segment of the American economy, according to the Centers for Disease Control and Prevention.

Current asthma prevalence was 8.8% for adults aged 18 years and older who worked in health care and social assistance in 2011-2016, which put them above those in education services (8.2%); arts, entertainment, and recreation (8.1%); accommodation and food services (7.7%); and finance and insurance (7.5%). The overall rate for all working adults was 6.8%, Jacek M. Mazurek, MD, PhD, and Girija Syamlal, MBBS, reported in the Morbidity and Mortality Weekly Report.

[email protected]

SOURCE: Mazurek JM, Syamlal G. MMWR. 2018 Apr 6;67(13):377-86.

Workers in the health care and social assistance industry are more likely to have asthma than those in any other segment of the American economy, according to the Centers for Disease Control and Prevention.

Current asthma prevalence was 8.8% for adults aged 18 years and older who worked in health care and social assistance in 2011-2016, which put them above those in education services (8.2%); arts, entertainment, and recreation (8.1%); accommodation and food services (7.7%); and finance and insurance (7.5%). The overall rate for all working adults was 6.8%, Jacek M. Mazurek, MD, PhD, and Girija Syamlal, MBBS, reported in the Morbidity and Mortality Weekly Report.

[email protected]

SOURCE: Mazurek JM, Syamlal G. MMWR. 2018 Apr 6;67(13):377-86.

Workers in the health care and social assistance industry are more likely to have asthma than those in any other segment of the American economy, according to the Centers for Disease Control and Prevention.

Current asthma prevalence was 8.8% for adults aged 18 years and older who worked in health care and social assistance in 2011-2016, which put them above those in education services (8.2%); arts, entertainment, and recreation (8.1%); accommodation and food services (7.7%); and finance and insurance (7.5%). The overall rate for all working adults was 6.8%, Jacek M. Mazurek, MD, PhD, and Girija Syamlal, MBBS, reported in the Morbidity and Mortality Weekly Report.

[email protected]

SOURCE: Mazurek JM, Syamlal G. MMWR. 2018 Apr 6;67(13):377-86.

Sepsis and critical care issues are in the spotlight at HM18, and these hot topics were the focus of the Monday education session, “He-Who-Shall-Not-Be-Named: Updates in Sepsis and Critical Care.”

Patricia Kritek, MD, EdM, of the University of Washington, Seattle, led an interactive and engaging session, educating attendees about the current research in sepsis and critical care areas so they would feel comfortable implementing the latest evidence into practice in the ICU.

The session focused on “what’s new” in critical care and sepsis from the literature published in the past year.

According to the National Center for Health Statistics at the Centers for Disease Control and Prevention, sepsis or septicemia patients averaged a 75% longer length of stay and were more than eight times likely to die, compared with patients hospitalized for other conditions.

“There has been a lot of discussion about steroids in sepsis that is potentially practice changing,” Dr. Kritek said in an interview. To tackle the always-tricky topic of steroids and sepsis, Dr. Kritek selected a trio of studies for review and discussion. In the first, vitamin C was potentially as effective as hydrocortisone and thiamine for the treatment of severe sepsis and septic shock (CHEST. 2017;151[6]:1229‐38). Another study addressed adjunctive glucocorticoid therapy for septic shock patients, and a third examined the use of hydrocortisone plus fludrocortisone for adults with septic shock.

The trials not involving vitamin C were published in the New England Journal of Medicine this year, conducted in Australia (2018;378:797‐808) and France (2018;378:809‐18), and included 3,658 and 1,241 adult sepsis patients, respectively. The studies were similar in size and design. Based on these two studies, hydrocortisone appears to shorten septic shock duration, and treatment with hydrocortisone and possibly fludrocortisone could be helpful for the more seriously ill patients, said Dr. Kritek. As for the value of vitamin C and thiamine, “the jury is still out,” she noted.

 

Sepsis and critical care issues are in the spotlight at HM18, and these hot topics were the focus of the Monday education session, “He-Who-Shall-Not-Be-Named: Updates in Sepsis and Critical Care.”

Patricia Kritek, MD, EdM, of the University of Washington, Seattle, led an interactive and engaging session, educating attendees about the current research in sepsis and critical care areas so they would feel comfortable implementing the latest evidence into practice in the ICU.

The session focused on “what’s new” in critical care and sepsis from the literature published in the past year.

According to the National Center for Health Statistics at the Centers for Disease Control and Prevention, sepsis or septicemia patients averaged a 75% longer length of stay and were more than eight times likely to die, compared with patients hospitalized for other conditions.

“There has been a lot of discussion about steroids in sepsis that is potentially practice changing,” Dr. Kritek said in an interview. To tackle the always-tricky topic of steroids and sepsis, Dr. Kritek selected a trio of studies for review and discussion. In the first, vitamin C was potentially as effective as hydrocortisone and thiamine for the treatment of severe sepsis and septic shock (CHEST. 2017;151[6]:1229‐38). Another study addressed adjunctive glucocorticoid therapy for septic shock patients, and a third examined the use of hydrocortisone plus fludrocortisone for adults with septic shock.

The trials not involving vitamin C were published in the New England Journal of Medicine this year, conducted in Australia (2018;378:797‐808) and France (2018;378:809‐18), and included 3,658 and 1,241 adult sepsis patients, respectively. The studies were similar in size and design. Based on these two studies, hydrocortisone appears to shorten septic shock duration, and treatment with hydrocortisone and possibly fludrocortisone could be helpful for the more seriously ill patients, said Dr. Kritek. As for the value of vitamin C and thiamine, “the jury is still out,” she noted.

 

Sepsis and critical care issues are in the spotlight at HM18, and these hot topics were the focus of the Monday education session, “He-Who-Shall-Not-Be-Named: Updates in Sepsis and Critical Care.”

Patricia Kritek, MD, EdM, of the University of Washington, Seattle, led an interactive and engaging session, educating attendees about the current research in sepsis and critical care areas so they would feel comfortable implementing the latest evidence into practice in the ICU.

The session focused on “what’s new” in critical care and sepsis from the literature published in the past year.

According to the National Center for Health Statistics at the Centers for Disease Control and Prevention, sepsis or septicemia patients averaged a 75% longer length of stay and were more than eight times likely to die, compared with patients hospitalized for other conditions.

“There has been a lot of discussion about steroids in sepsis that is potentially practice changing,” Dr. Kritek said in an interview. To tackle the always-tricky topic of steroids and sepsis, Dr. Kritek selected a trio of studies for review and discussion. In the first, vitamin C was potentially as effective as hydrocortisone and thiamine for the treatment of severe sepsis and septic shock (CHEST. 2017;151[6]:1229‐38). Another study addressed adjunctive glucocorticoid therapy for septic shock patients, and a third examined the use of hydrocortisone plus fludrocortisone for adults with septic shock.

The trials not involving vitamin C were published in the New England Journal of Medicine this year, conducted in Australia (2018;378:797‐808) and France (2018;378:809‐18), and included 3,658 and 1,241 adult sepsis patients, respectively. The studies were similar in size and design. Based on these two studies, hydrocortisone appears to shorten septic shock duration, and treatment with hydrocortisone and possibly fludrocortisone could be helpful for the more seriously ill patients, said Dr. Kritek. As for the value of vitamin C and thiamine, “the jury is still out,” she noted.