Number of malpractice claims per 100 physician coverage years for hospitalists, according to an analysis of 52,000 coded medical malpractice claims from 20 different malpractice insurance programs for injuries incurred between 1997 and 2011. Nonhospitalist internal medicine physicians had a rate 3.5 times greater, and emergency physicians had a rate seven times higher than hospitalists. An accompanying editorial in the Journal of Hospital Medicine calls this result, the first analysis of data specifically identifying hospitalists, surprising “because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.”

Larry Beresford is a freelance writer in Alameda, Calif.

Number of malpractice claims per 100 physician coverage years for hospitalists, according to an analysis of 52,000 coded medical malpractice claims from 20 different malpractice insurance programs for injuries incurred between 1997 and 2011. Nonhospitalist internal medicine physicians had a rate 3.5 times greater, and emergency physicians had a rate seven times higher than hospitalists. An accompanying editorial in the Journal of Hospital Medicine calls this result, the first analysis of data specifically identifying hospitalists, surprising “because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.”

Larry Beresford is a freelance writer in Alameda, Calif.

Number of malpractice claims per 100 physician coverage years for hospitalists, according to an analysis of 52,000 coded medical malpractice claims from 20 different malpractice insurance programs for injuries incurred between 1997 and 2011. Nonhospitalist internal medicine physicians had a rate 3.5 times greater, and emergency physicians had a rate seven times higher than hospitalists. An accompanying editorial in the Journal of Hospital Medicine calls this result, the first analysis of data specifically identifying hospitalists, surprising “because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.”

Larry Beresford is a freelance writer in Alameda, Calif.

A recent article in The North Jersey Record describes how art is being used to help manage hospitalized patients’ pain and anxiety.¹ At Englewood (N.J.) Hospital and Medical Center, patients wheeled down a long corridor to the diagnostic testing department pass a dazzling array of 50 original art works—floral designs, landscapes, and abstracts—curated by the Art School at Old Church in Demarest.

Half of U.S. hospitals have some sort of art program, according to a 2009 report from the Society for the Arts in Healthcare. Although the research is still in its infancy, evidence suggests that programs incorporating art therapy can help reduce stress, anxiety, and pain in patients with cancer and other conditions, while increasing their satisfaction with their care.^2,3,4

UK Arts in Healthcare at University of Kentucky HealthCare in Lexington brings the visual arts into health facilities and presents performing arts, music, and art therapies at Albert B. Chandler Hospital and other UK hospitals and clinics. Art in clinic waiting areas at UK improved patient satisfaction scores, which got the attention of hospital administrators, says Arts in Healthcare Program Director Jacqueline Hamilton.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Petrick J. Art is used to help healing process in hospitals. The North Jersey Record. January 25, 2015. Available at: http://www.northjersey.com/arts-and-entertainment/art/art-is-used-to-help-healing-process-in-hospitals-1.1251254. Accessed March 9, 2015.
2. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med. 2013;173(11):960-969.
3. Thyme KE, Sundin EC, Wiberg B, Öster I, Aström S, Lindh J. Individual brief art therapy can be helpful for women with breast cancer: a randomized controlled clinical study. Palliat Support Care. 2009;7(1):87-95.
4. Wood MJM, Molassiotis A, Payne S. What research evidence is there for the use of art therapy in the management of symptoms in adults with cancer? A systematic review. Psychooncology. 2011;20(2):135-145.

A recent article in The North Jersey Record describes how art is being used to help manage hospitalized patients’ pain and anxiety.¹ At Englewood (N.J.) Hospital and Medical Center, patients wheeled down a long corridor to the diagnostic testing department pass a dazzling array of 50 original art works—floral designs, landscapes, and abstracts—curated by the Art School at Old Church in Demarest.

Half of U.S. hospitals have some sort of art program, according to a 2009 report from the Society for the Arts in Healthcare. Although the research is still in its infancy, evidence suggests that programs incorporating art therapy can help reduce stress, anxiety, and pain in patients with cancer and other conditions, while increasing their satisfaction with their care.^2,3,4

UK Arts in Healthcare at University of Kentucky HealthCare in Lexington brings the visual arts into health facilities and presents performing arts, music, and art therapies at Albert B. Chandler Hospital and other UK hospitals and clinics. Art in clinic waiting areas at UK improved patient satisfaction scores, which got the attention of hospital administrators, says Arts in Healthcare Program Director Jacqueline Hamilton.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Petrick J. Art is used to help healing process in hospitals. The North Jersey Record. January 25, 2015. Available at: http://www.northjersey.com/arts-and-entertainment/art/art-is-used-to-help-healing-process-in-hospitals-1.1251254. Accessed March 9, 2015.
2. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med. 2013;173(11):960-969.
3. Thyme KE, Sundin EC, Wiberg B, Öster I, Aström S, Lindh J. Individual brief art therapy can be helpful for women with breast cancer: a randomized controlled clinical study. Palliat Support Care. 2009;7(1):87-95.
4. Wood MJM, Molassiotis A, Payne S. What research evidence is there for the use of art therapy in the management of symptoms in adults with cancer? A systematic review. Psychooncology. 2011;20(2):135-145.

A recent article in The North Jersey Record describes how art is being used to help manage hospitalized patients’ pain and anxiety.¹ At Englewood (N.J.) Hospital and Medical Center, patients wheeled down a long corridor to the diagnostic testing department pass a dazzling array of 50 original art works—floral designs, landscapes, and abstracts—curated by the Art School at Old Church in Demarest.

Half of U.S. hospitals have some sort of art program, according to a 2009 report from the Society for the Arts in Healthcare. Although the research is still in its infancy, evidence suggests that programs incorporating art therapy can help reduce stress, anxiety, and pain in patients with cancer and other conditions, while increasing their satisfaction with their care.^2,3,4

UK Arts in Healthcare at University of Kentucky HealthCare in Lexington brings the visual arts into health facilities and presents performing arts, music, and art therapies at Albert B. Chandler Hospital and other UK hospitals and clinics. Art in clinic waiting areas at UK improved patient satisfaction scores, which got the attention of hospital administrators, says Arts in Healthcare Program Director Jacqueline Hamilton.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Petrick J. Art is used to help healing process in hospitals. The North Jersey Record. January 25, 2015. Available at: http://www.northjersey.com/arts-and-entertainment/art/art-is-used-to-help-healing-process-in-hospitals-1.1251254. Accessed March 9, 2015.
2. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med. 2013;173(11):960-969.
3. Thyme KE, Sundin EC, Wiberg B, Öster I, Aström S, Lindh J. Individual brief art therapy can be helpful for women with breast cancer: a randomized controlled clinical study. Palliat Support Care. 2009;7(1):87-95.
4. Wood MJM, Molassiotis A, Payne S. What research evidence is there for the use of art therapy in the management of symptoms in adults with cancer? A systematic review. Psychooncology. 2011;20(2):135-145.

Ashish K. Jha, MD, MPH, K.T. Li Professor of international health in the department of health policy and management at the Harvard School of Public Health and director of the Harvard Global Health Institute in Boston, is both a practicing hospitalist and a widely published researcher in the middle of a teeming national debate about hospital readmissions policy.¹ He’s seen his fledgling field of hospital-based internists grow from a few hundred two decades ago to nearly 50,000 hospitalists spanning every state. He’s also seen changes in the role hospitalists play in the inpatient setting.

“Now, when it’s time for my patient to get discharged, I ask a lot of questions like, ‘Who is with you at home? How will you get your medications or your groceries?’” says Dr. Jha, who practices hospital medicine at the VA Boston Healthcare System.

Hospitalist care went under Medicare’s microscope in October 2012, when the Hospital Readmissions Reduction Program (HRRP) began penalizing hospitals with higher-than-predicted rates of 30-day readmissions for certain common conditions (see “Optimal Discharge Checklist for Hospitalists”). HRRP places hospitalists under greater scrutiny for things that happen to their patients after discharge, whether to home or another healthcare facility. In one swoop, the program changed how the healthcare system views care transitions, continuity of care, teamwork, collaboration, and the post-discharge period.

Experts in improving transitions of care—which, it is hoped, would ameliorate the problems that lead to readmissions—emphasize the importance of teamwork across disciplines, specialties, and care settings; dialogue and collaboration between providers; and the formation of community coalitions and integrated systems of care.

Many of the factors that influence the likelihood of readmission are nonmedical, however: socioeconomic status, health literacy, home environment, adherence to prescribed medications, and the ability to make—and keep—follow-up appointments. So, while social variables are an essential part of the readmission conversation, a hospitalist often has no remedy to address—let alone prevent—them.

“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord.”—David J. Yu, MD, MBA, SFHM, medical director, adult inpatient medicine service, Presbyterian Hospital, Albuquerque, N.M.

And therein lies the debate: At what point do hospitalists stop being responsible for discharged patients?

“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord,” says David J. Yu, MD, MBA, FACP, SFHM, medical director of the adult inpatient medicine service at Presbyterian Hospital in Albuquerque, N.M.

Dr. Yu agrees that hospitalists are responsible for the quality of their discharges. Readmissions, he says, are a system issue. Although hospitalists have a responsibility to help drive quality improvement in the hospital, he says it makes little sense to hold the hospitalist responsible for what happens to the patient after discharge.

“I believe that when we talk about hospitalist-staffed post-discharge clinics and things like that, we’re asking the wrong questions,” he says. “We’re turning the hospitalist into a temporary PCP. Those things are only temporary solutions.”

Some hospitalists see this issue as black and white, arguing that their focus should be on caring for “inpatients,” working strictly according to the definition of a hospitalist. They ask a very simple question: How long can responsibility linger once the patient exits our facility?

Others, like Dr. Jha, choose to “own” care transitions into the post-discharge period.

“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job,” Dr. Jha says. “Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge. We follow up on pending lab results. The hospital makes a post-discharge phone call. We’re reachable by phone. We’re still taking care of the patient but in a different way.”

Dr. Jha agrees it’s not reasonable to expect hospitalists to take responsibility for what happens to their patients 30 days after discharge, the standard of such performance models as HRRP.

“But I believe you can push me and my team to step up for a few more days,” he says. “I’ve had patients come back to the hospital the next day. Hey, that means I dropped the ball.”

Yet, the middle ground, from a few days after discharge to 30 days, can seem like an eternity.

“If we think our role completely ends at the time of discharge, what tends to happen is we take our foot off the gas,” says Win Whitcomb, MD, MHM, co-founder of SHM, practicing hospitalist, and CMO of Remedy Partners, a firm specializing in bundled payment programs. “We back off from the patient being discharged and start focusing on the next acutely ill patient who just got admitted.”

“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job. Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge.”—Ashish K. Jha, MD, MPH, K.T. Li Professor of international health, Harvard School of Public Health, director, Harvard Global Health Institute, hospitalist, VA Boston Healthcare System

At a minimum, Dr. Whitcomb says he believes that hospitalists should place a direct phone call to the PCP, preferably before the patient leaves the hospital, although he acknowledges that this is the exception rather than the rule for most hospitalists today.

“You learn things about the patients and their history,” he says, that might be important to the next provider.

Pending lab tests at the time of discharge are another big issue, most experts on readmissions agree. If the hospital doesn’t have a system for ensuring that these results are properly passed on to the next provider of care, the hospitalist group should be spearheading a quality improvement (QI) process to make it happen. Even so, Dr. Whitcomb says hospitalists should not be trying to fix these problems in a vacuum. For example, they should partner with others in the hospital working on readmissions issues and coordinate their post-discharge phone calls to patients with other groups that may be placing similar calls.

“The individual hospitalist is responsible for working with the hospital team to ensure that the patient understands the post-discharge plan of care, that medications are reconciled, and that there is a system for transmitting information to the PCP,” he says.

What Is a Satisfactory Discharge/Handoff?

Experts can agree on one thing: A successful discharge (or handoff) is paramount to preventing what are considered “avoidable” readmissions (see “What We Already Know about Hospital Readmissions”). Exactly what a successful discharge looks like, however, is not as easily defined.

Most agree hospitalists are responsible for making sure that patients understand their condition, treatment plan, what to watch for, and where to go or who to call in a crisis. This means short, digestible, actionable, tailored advice utilizing “teach-back” and other techniques that clarify for the physician whether patients truly understand what they need to know. Some hospitalist groups task a member of the group to be available for the questions that can arise in the first few days after discharge. Some argue hospitalists should provide contact information, even a pager number, to patients going home from the hospital.

Hospitalists should communicate critical information about patient care to the outpatient provider via faxed or e-mailed discharge summaries, phone calls, or other prearranged forms of contact. Breakdowns in this communication have been well documented, as in the 2007 JAMA study that found that only 12% to 34% of discharge summaries had reached the PCP by the time of the first post-discharge medical visit.² Other studies have found that PCPs were not aware of important test results for recently discharged patients roughly 60% of the time, and one in three adult patients discharged from hospital to community didn’t even see a physician within 30 days.^3.4

“Most of this is common sense and courtesy but hard to deliver reliably.”—Gregory Maynard, MD, MSc, SFHM, clinical professor, chief quality officer, University of California Davis Medical Center, Sacramento

Seriously or chronically ill hospitalized patients need help making an appointment for their first post-discharge medical visit; staff should also work with the patient and/or caregiver to make sure they have transportation and can keep that appointment. Patients who don’t have a relationship with a PCP or can’t get an appointment soon enough to forestall potential bounce-backs face an additional challenge.

Some hospitals have developed relationships with community clinics, specialty groups, and other providers who might be able to see the patient more quickly. Others have developed post-discharge clinics on the hospital campus, where the patient can come back for a first follow-up visit with a hospitalist. A medication reconciliation process, drawing upon a best possible medication history conducted within the hospital, is important.

Although it makes sense to try to figure out who needs the most attention, Dr. Maynard says there is no national consensus about the optimal tool for assessing the patient’s risk of rehospitalization. A number of factors considered likely indicators can help focus the team’s attention on those at higher risk, such as patients who are very elderly, have certain diseases like heart failure, take problem-prone medications like warfarin or insulin, have complex medical needs or social circumstances, suffer a lack of financial resources, and have behavioral health overlays.

SHM’s quality improvement toolkit, Project BOOST, offers expert mentored implementation and a variety of other resources to help hospitals get a handle on their care transitions. BOOST now features a readmissions risk assessment tool called the “8Ps”.

SHM has been on record since November 10, 2010, saying that “reducing unnecessary readmissions through improvements in the hospital discharge process is a high priority” for the society and its members, because readmissions are a cost for both the system and the patient—and are often preventable.⁵ Project BOOST is the society’s major contribution to improving care transitions, but SHM also offers other readmissions resources for hospitalists through its Leadership Academy, Quality and Safety Educators Academy, and other QI tools, says Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Hospital in Baltimore and a former SHM president.

Dr. Howell agrees a hospitalist’s responsibility doesn’t end at the hospital door but acknowledges that it is “difficult to say exactly where it ends.”

“I’m not sure we ever end our relationship with our patients, whether they come back to the hospital or not,” he says. “In our practice, we are available to the patient by telephone, with no formal end point.

“I feel more comfortable as a hospitalist with my responsibility ending when I have completed a good handoff to the next provider,” he says, adding that “good handoff” means that the receiving provider acknowledges receiving it and has a chance to ask questions. “There may be information I can provide to the outpatient provider or, if the patient is readmitted, to whomever cares for them next in the hospital.”

Hospitalists have played a key role in highlighting the problems of a fragmented healthcare system, with its inadequate care transitions and follow-up, problems that long preceded the emergence of hospital medicine, Dr. Howell says.

“As a hospitalist, I want my service to try to make the world a better place and to fix the broken incentives that are now in place,” he says. “Whether or not you believe that hospital medicine has introduced its own dyssynchronies on transfers of care, it’s still our responsibility to try to improve the processes.”

Financial Accountability

Healthcare is moving toward integration of services, a process that muddies the waters somewhat when it comes to determining who is accountable for readmissions, says Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy.

“Every one of our members who is actively engaged in integration tells us that not all of those readmissions we might have thought preventable are,” she says, “but they were also surprised at how many we could prevent with better education and communication.”

The new penalties for readmissions are encouraging hospitals do a better job with their care transitions, Foster says. That pressure has helped hospitals to deliver better care, and hospitalists are a “critical piece of the puzzle.”

“When you get patients coming back, analyze what went wrong and reach outside your four walls to other providers,” Foster says. “Those are important opportunities for improvement.”

Rachel George, MD, MBA, SFHM, CPE, now system vice president for Presence Health in Chicago but formerly central business unit president for Brentwood, Tenn.-based Cogent Healthcare, says that when she was at Cogent, the company developed a readmissions playbook for its physicians. Cogent, which was acquired by Seattle’s Sound Physicians late last year, included readmissions in the quality conversations it had with its contracting hospitals, she says, although those conversations varied widely in terms of the resources dedicated to improving care transitions.

“How do you make sure the necessary communication happens?” Dr. George poses. “We believe everybody has a role, but in the hospital, the hospitalist is definitely the captain of the ship.

“It’s not as clear who is the captain of the ship when the patient goes home. Do we need to send someone out to the patient’s house to see what they have in their medicine cabinet?”

Ultimately, she says, it is up to the individual provider to use resources and implement processes that have been developed.

“Cogent always believed in quality as a business strategy, putting part of its payment at risk, but it was not clear that it could use incentives for readmissions rates for individual hospitalists. Hospitals’ incentives are undergoing evolution and are very different than physicians.’”

Randy Ferrance, DC, MD, FAAP, SFHM, medical director of the hospitalist service at Riverside Tappahannock Hospital in rural Virginia, says his hospital recently incorporated readmissions rates into the quality metrics that factor into the five-member hospitalist group’s collective bonus pay.

“The problem with readmissions incentives is who gets assigned the ‘blame,’” he says.

Incorporating readmissions into bonuses and penalties for hospitalist groups is likely to become an increasing trend, says Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. She and partner John Nelson MD, MHM, are seeing that trend “as a bonus component in our clients’ incentive plans, whereas five years ago it was uncommon.”

SHM practice data support this observation, Flores says, with 46.1% of adult medicine hospitalist groups in 2013 reporting the use of readmissions rates as part of performance incentives.⁶

Dr. Nelson, a co-founder of SHM and a longtime practice management columnist for The Hospitalist, says a bonus based on readmissions rates might be reasonable, although it’s important not to create incentives that deny the patient a needed return to the hospital in order to ensure that the hospitalist gets the bonus. Competing pressures on performance for both shorter lengths of stay in the hospital and fewer readmissions complicate incentives for hospitalists. “Compensation incentives [bonuses] based on both length of stay and readmissions are problematic, because they could potentially be construed as incentives to deny needed care, so [they] are best avoided,” Dr. Nelson says.

The Wrong Target?

HRRP has generated a huge amount of commentary in the health policy media. Some charge that it unfairly penalizes teaching hospitals and large institutions, as well as those serving a greater proportion of patients with lower socioeconomic status or those with fewer social supports.⁷

In a New England Journal of Medicine editorial, Dr. Jha and co-author Karen Joynt, MD, MPH, ask “whether the hospital is the appropriate entity to be held accountable for readmissions, given that the events and circumstances that predict readmissions largely take place outside the hospital’s walls.”⁷ Dr. Jha doesn’t consider readmissions rates a true measure of a hospital’s quality.

“I think the real goal should be improving transitions of care—with better quality measures for assessing good transitions,” he says. “You can improve transitions of care without improving readmissions rates.”

A serious disconnect exists between readmissions penalties and evidence for strategies that might be expected to prevent them, says Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Lenox Hill Hospital in New York City and blogger for The Hospital Leader.

“As much as we might be held accountable for certain outcomes like readmissions, the reality is we can’t control them,” he says. “There are so many other factors out there that we don’t know about. Is the readmissions rate a good proxy for quality? We’ve seen evidence that it doesn’t relate very well to mortality rates.”⁸

Assessing blame can be a slippery slope, some experts say.

“My first message to my hospitalist colleagues—myself included—is to try to stop reacting as if this were about individual blame for the discharging hospitalist,” says Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies, who practices HM at Newton-Wellesley Hospital in Newton, Mass. “Certainly, that’s not how CMS views it. They are incentivizing hospitals and providers to improve systems of care and provide new and better types of continuing care.”

Dr. Boutwell, who is also an attending physician at Massachusetts General Hospital in Boston, sees the good in programs such as HRRP.

“[The program] has done a good job of mobilizing resources where previously very little attention had been given,” she says. “It aimed to catalyze investments in readmissions reduction, and that has occurred.”

Often, when hospitalists don’t do an “adequate job” of preparing their patients for discharges, including failures in communicating with outpatient providers, patients are in a catch-22.

“In many cases the PCP may tell the patient, ‘I don’t know enough about your case. I need you to go back to the hospital,’” Dr. Boutwell says. “That’s a big part of what we’re trying to avoid.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368(13):1175-1177.
2. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
3. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-128.
4. Sommers A, Cunningham PJ. Physician visits after hospital discharge: implications for reducing readmissions. National Institute for Health Care Reform Research Brief No. 6. December 2011. Available at: http://www.nihcr.org/Reducing_Readmissions.html. Accessed March 12, 2015.
5. Society of Hospital Medicine. Reducing readmissions and improving care transitions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=27513. Accessed March 12, 2015.
6. Society of Hospital Medicine. 2014 State of Hospital Medicine Report. September 5, 2014. Philadelphia: Society of Hospital Medicine; 2014:84.
7. Abelson R. Hospitals question Medicare rules on readmissions. The New York Times. March 29, 2013. Available at: http://www.nytimes.com/2013/03/30/business/hospitals-question-fairness-of-new-medicare-rules.html. Accessed March 12, 2015.
8. Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-593.

Ashish K. Jha, MD, MPH, K.T. Li Professor of international health in the department of health policy and management at the Harvard School of Public Health and director of the Harvard Global Health Institute in Boston, is both a practicing hospitalist and a widely published researcher in the middle of a teeming national debate about hospital readmissions policy.¹ He’s seen his fledgling field of hospital-based internists grow from a few hundred two decades ago to nearly 50,000 hospitalists spanning every state. He’s also seen changes in the role hospitalists play in the inpatient setting.

“Now, when it’s time for my patient to get discharged, I ask a lot of questions like, ‘Who is with you at home? How will you get your medications or your groceries?’” says Dr. Jha, who practices hospital medicine at the VA Boston Healthcare System.

Hospitalist care went under Medicare’s microscope in October 2012, when the Hospital Readmissions Reduction Program (HRRP) began penalizing hospitals with higher-than-predicted rates of 30-day readmissions for certain common conditions (see “Optimal Discharge Checklist for Hospitalists”). HRRP places hospitalists under greater scrutiny for things that happen to their patients after discharge, whether to home or another healthcare facility. In one swoop, the program changed how the healthcare system views care transitions, continuity of care, teamwork, collaboration, and the post-discharge period.

Experts in improving transitions of care—which, it is hoped, would ameliorate the problems that lead to readmissions—emphasize the importance of teamwork across disciplines, specialties, and care settings; dialogue and collaboration between providers; and the formation of community coalitions and integrated systems of care.

Many of the factors that influence the likelihood of readmission are nonmedical, however: socioeconomic status, health literacy, home environment, adherence to prescribed medications, and the ability to make—and keep—follow-up appointments. So, while social variables are an essential part of the readmission conversation, a hospitalist often has no remedy to address—let alone prevent—them.

“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord.”—David J. Yu, MD, MBA, SFHM, medical director, adult inpatient medicine service, Presbyterian Hospital, Albuquerque, N.M.

And therein lies the debate: At what point do hospitalists stop being responsible for discharged patients?

“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord,” says David J. Yu, MD, MBA, FACP, SFHM, medical director of the adult inpatient medicine service at Presbyterian Hospital in Albuquerque, N.M.

Dr. Yu agrees that hospitalists are responsible for the quality of their discharges. Readmissions, he says, are a system issue. Although hospitalists have a responsibility to help drive quality improvement in the hospital, he says it makes little sense to hold the hospitalist responsible for what happens to the patient after discharge.

“I believe that when we talk about hospitalist-staffed post-discharge clinics and things like that, we’re asking the wrong questions,” he says. “We’re turning the hospitalist into a temporary PCP. Those things are only temporary solutions.”

Some hospitalists see this issue as black and white, arguing that their focus should be on caring for “inpatients,” working strictly according to the definition of a hospitalist. They ask a very simple question: How long can responsibility linger once the patient exits our facility?

Others, like Dr. Jha, choose to “own” care transitions into the post-discharge period.

“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job,” Dr. Jha says. “Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge. We follow up on pending lab results. The hospital makes a post-discharge phone call. We’re reachable by phone. We’re still taking care of the patient but in a different way.”

Dr. Jha agrees it’s not reasonable to expect hospitalists to take responsibility for what happens to their patients 30 days after discharge, the standard of such performance models as HRRP.

“But I believe you can push me and my team to step up for a few more days,” he says. “I’ve had patients come back to the hospital the next day. Hey, that means I dropped the ball.”

Yet, the middle ground, from a few days after discharge to 30 days, can seem like an eternity.

“If we think our role completely ends at the time of discharge, what tends to happen is we take our foot off the gas,” says Win Whitcomb, MD, MHM, co-founder of SHM, practicing hospitalist, and CMO of Remedy Partners, a firm specializing in bundled payment programs. “We back off from the patient being discharged and start focusing on the next acutely ill patient who just got admitted.”

“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job. Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge.”—Ashish K. Jha, MD, MPH, K.T. Li Professor of international health, Harvard School of Public Health, director, Harvard Global Health Institute, hospitalist, VA Boston Healthcare System

At a minimum, Dr. Whitcomb says he believes that hospitalists should place a direct phone call to the PCP, preferably before the patient leaves the hospital, although he acknowledges that this is the exception rather than the rule for most hospitalists today.

“You learn things about the patients and their history,” he says, that might be important to the next provider.

Pending lab tests at the time of discharge are another big issue, most experts on readmissions agree. If the hospital doesn’t have a system for ensuring that these results are properly passed on to the next provider of care, the hospitalist group should be spearheading a quality improvement (QI) process to make it happen. Even so, Dr. Whitcomb says hospitalists should not be trying to fix these problems in a vacuum. For example, they should partner with others in the hospital working on readmissions issues and coordinate their post-discharge phone calls to patients with other groups that may be placing similar calls.

“The individual hospitalist is responsible for working with the hospital team to ensure that the patient understands the post-discharge plan of care, that medications are reconciled, and that there is a system for transmitting information to the PCP,” he says.

What Is a Satisfactory Discharge/Handoff?

Experts can agree on one thing: A successful discharge (or handoff) is paramount to preventing what are considered “avoidable” readmissions (see “What We Already Know about Hospital Readmissions”). Exactly what a successful discharge looks like, however, is not as easily defined.

Most agree hospitalists are responsible for making sure that patients understand their condition, treatment plan, what to watch for, and where to go or who to call in a crisis. This means short, digestible, actionable, tailored advice utilizing “teach-back” and other techniques that clarify for the physician whether patients truly understand what they need to know. Some hospitalist groups task a member of the group to be available for the questions that can arise in the first few days after discharge. Some argue hospitalists should provide contact information, even a pager number, to patients going home from the hospital.

Hospitalists should communicate critical information about patient care to the outpatient provider via faxed or e-mailed discharge summaries, phone calls, or other prearranged forms of contact. Breakdowns in this communication have been well documented, as in the 2007 JAMA study that found that only 12% to 34% of discharge summaries had reached the PCP by the time of the first post-discharge medical visit.² Other studies have found that PCPs were not aware of important test results for recently discharged patients roughly 60% of the time, and one in three adult patients discharged from hospital to community didn’t even see a physician within 30 days.^3.4

“Most of this is common sense and courtesy but hard to deliver reliably.”—Gregory Maynard, MD, MSc, SFHM, clinical professor, chief quality officer, University of California Davis Medical Center, Sacramento

Seriously or chronically ill hospitalized patients need help making an appointment for their first post-discharge medical visit; staff should also work with the patient and/or caregiver to make sure they have transportation and can keep that appointment. Patients who don’t have a relationship with a PCP or can’t get an appointment soon enough to forestall potential bounce-backs face an additional challenge.

Some hospitals have developed relationships with community clinics, specialty groups, and other providers who might be able to see the patient more quickly. Others have developed post-discharge clinics on the hospital campus, where the patient can come back for a first follow-up visit with a hospitalist. A medication reconciliation process, drawing upon a best possible medication history conducted within the hospital, is important.

Although it makes sense to try to figure out who needs the most attention, Dr. Maynard says there is no national consensus about the optimal tool for assessing the patient’s risk of rehospitalization. A number of factors considered likely indicators can help focus the team’s attention on those at higher risk, such as patients who are very elderly, have certain diseases like heart failure, take problem-prone medications like warfarin or insulin, have complex medical needs or social circumstances, suffer a lack of financial resources, and have behavioral health overlays.

SHM’s quality improvement toolkit, Project BOOST, offers expert mentored implementation and a variety of other resources to help hospitals get a handle on their care transitions. BOOST now features a readmissions risk assessment tool called the “8Ps”.

SHM has been on record since November 10, 2010, saying that “reducing unnecessary readmissions through improvements in the hospital discharge process is a high priority” for the society and its members, because readmissions are a cost for both the system and the patient—and are often preventable.⁵ Project BOOST is the society’s major contribution to improving care transitions, but SHM also offers other readmissions resources for hospitalists through its Leadership Academy, Quality and Safety Educators Academy, and other QI tools, says Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Hospital in Baltimore and a former SHM president.

Dr. Howell agrees a hospitalist’s responsibility doesn’t end at the hospital door but acknowledges that it is “difficult to say exactly where it ends.”

“I’m not sure we ever end our relationship with our patients, whether they come back to the hospital or not,” he says. “In our practice, we are available to the patient by telephone, with no formal end point.

“I feel more comfortable as a hospitalist with my responsibility ending when I have completed a good handoff to the next provider,” he says, adding that “good handoff” means that the receiving provider acknowledges receiving it and has a chance to ask questions. “There may be information I can provide to the outpatient provider or, if the patient is readmitted, to whomever cares for them next in the hospital.”

Hospitalists have played a key role in highlighting the problems of a fragmented healthcare system, with its inadequate care transitions and follow-up, problems that long preceded the emergence of hospital medicine, Dr. Howell says.

“As a hospitalist, I want my service to try to make the world a better place and to fix the broken incentives that are now in place,” he says. “Whether or not you believe that hospital medicine has introduced its own dyssynchronies on transfers of care, it’s still our responsibility to try to improve the processes.”

Financial Accountability

Healthcare is moving toward integration of services, a process that muddies the waters somewhat when it comes to determining who is accountable for readmissions, says Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy.

“Every one of our members who is actively engaged in integration tells us that not all of those readmissions we might have thought preventable are,” she says, “but they were also surprised at how many we could prevent with better education and communication.”

The new penalties for readmissions are encouraging hospitals do a better job with their care transitions, Foster says. That pressure has helped hospitals to deliver better care, and hospitalists are a “critical piece of the puzzle.”

“When you get patients coming back, analyze what went wrong and reach outside your four walls to other providers,” Foster says. “Those are important opportunities for improvement.”

Rachel George, MD, MBA, SFHM, CPE, now system vice president for Presence Health in Chicago but formerly central business unit president for Brentwood, Tenn.-based Cogent Healthcare, says that when she was at Cogent, the company developed a readmissions playbook for its physicians. Cogent, which was acquired by Seattle’s Sound Physicians late last year, included readmissions in the quality conversations it had with its contracting hospitals, she says, although those conversations varied widely in terms of the resources dedicated to improving care transitions.

“How do you make sure the necessary communication happens?” Dr. George poses. “We believe everybody has a role, but in the hospital, the hospitalist is definitely the captain of the ship.

“It’s not as clear who is the captain of the ship when the patient goes home. Do we need to send someone out to the patient’s house to see what they have in their medicine cabinet?”

Ultimately, she says, it is up to the individual provider to use resources and implement processes that have been developed.

“Cogent always believed in quality as a business strategy, putting part of its payment at risk, but it was not clear that it could use incentives for readmissions rates for individual hospitalists. Hospitals’ incentives are undergoing evolution and are very different than physicians.’”

Randy Ferrance, DC, MD, FAAP, SFHM, medical director of the hospitalist service at Riverside Tappahannock Hospital in rural Virginia, says his hospital recently incorporated readmissions rates into the quality metrics that factor into the five-member hospitalist group’s collective bonus pay.

“The problem with readmissions incentives is who gets assigned the ‘blame,’” he says.

Incorporating readmissions into bonuses and penalties for hospitalist groups is likely to become an increasing trend, says Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. She and partner John Nelson MD, MHM, are seeing that trend “as a bonus component in our clients’ incentive plans, whereas five years ago it was uncommon.”

SHM practice data support this observation, Flores says, with 46.1% of adult medicine hospitalist groups in 2013 reporting the use of readmissions rates as part of performance incentives.⁶

Dr. Nelson, a co-founder of SHM and a longtime practice management columnist for The Hospitalist, says a bonus based on readmissions rates might be reasonable, although it’s important not to create incentives that deny the patient a needed return to the hospital in order to ensure that the hospitalist gets the bonus. Competing pressures on performance for both shorter lengths of stay in the hospital and fewer readmissions complicate incentives for hospitalists. “Compensation incentives [bonuses] based on both length of stay and readmissions are problematic, because they could potentially be construed as incentives to deny needed care, so [they] are best avoided,” Dr. Nelson says.

The Wrong Target?

HRRP has generated a huge amount of commentary in the health policy media. Some charge that it unfairly penalizes teaching hospitals and large institutions, as well as those serving a greater proportion of patients with lower socioeconomic status or those with fewer social supports.⁷

In a New England Journal of Medicine editorial, Dr. Jha and co-author Karen Joynt, MD, MPH, ask “whether the hospital is the appropriate entity to be held accountable for readmissions, given that the events and circumstances that predict readmissions largely take place outside the hospital’s walls.”⁷ Dr. Jha doesn’t consider readmissions rates a true measure of a hospital’s quality.

“I think the real goal should be improving transitions of care—with better quality measures for assessing good transitions,” he says. “You can improve transitions of care without improving readmissions rates.”

A serious disconnect exists between readmissions penalties and evidence for strategies that might be expected to prevent them, says Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Lenox Hill Hospital in New York City and blogger for The Hospital Leader.

“As much as we might be held accountable for certain outcomes like readmissions, the reality is we can’t control them,” he says. “There are so many other factors out there that we don’t know about. Is the readmissions rate a good proxy for quality? We’ve seen evidence that it doesn’t relate very well to mortality rates.”⁸

Assessing blame can be a slippery slope, some experts say.

“My first message to my hospitalist colleagues—myself included—is to try to stop reacting as if this were about individual blame for the discharging hospitalist,” says Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies, who practices HM at Newton-Wellesley Hospital in Newton, Mass. “Certainly, that’s not how CMS views it. They are incentivizing hospitals and providers to improve systems of care and provide new and better types of continuing care.”

Dr. Boutwell, who is also an attending physician at Massachusetts General Hospital in Boston, sees the good in programs such as HRRP.

“[The program] has done a good job of mobilizing resources where previously very little attention had been given,” she says. “It aimed to catalyze investments in readmissions reduction, and that has occurred.”

Often, when hospitalists don’t do an “adequate job” of preparing their patients for discharges, including failures in communicating with outpatient providers, patients are in a catch-22.

“In many cases the PCP may tell the patient, ‘I don’t know enough about your case. I need you to go back to the hospital,’” Dr. Boutwell says. “That’s a big part of what we’re trying to avoid.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368(13):1175-1177.
2. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
3. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-128.
4. Sommers A, Cunningham PJ. Physician visits after hospital discharge: implications for reducing readmissions. National Institute for Health Care Reform Research Brief No. 6. December 2011. Available at: http://www.nihcr.org/Reducing_Readmissions.html. Accessed March 12, 2015.
5. Society of Hospital Medicine. Reducing readmissions and improving care transitions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=27513. Accessed March 12, 2015.
6. Society of Hospital Medicine. 2014 State of Hospital Medicine Report. September 5, 2014. Philadelphia: Society of Hospital Medicine; 2014:84.
7. Abelson R. Hospitals question Medicare rules on readmissions. The New York Times. March 29, 2013. Available at: http://www.nytimes.com/2013/03/30/business/hospitals-question-fairness-of-new-medicare-rules.html. Accessed March 12, 2015.
8. Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-593.

Ashish K. Jha, MD, MPH, K.T. Li Professor of international health in the department of health policy and management at the Harvard School of Public Health and director of the Harvard Global Health Institute in Boston, is both a practicing hospitalist and a widely published researcher in the middle of a teeming national debate about hospital readmissions policy.¹ He’s seen his fledgling field of hospital-based internists grow from a few hundred two decades ago to nearly 50,000 hospitalists spanning every state. He’s also seen changes in the role hospitalists play in the inpatient setting.

“Now, when it’s time for my patient to get discharged, I ask a lot of questions like, ‘Who is with you at home? How will you get your medications or your groceries?’” says Dr. Jha, who practices hospital medicine at the VA Boston Healthcare System.

Hospitalist care went under Medicare’s microscope in October 2012, when the Hospital Readmissions Reduction Program (HRRP) began penalizing hospitals with higher-than-predicted rates of 30-day readmissions for certain common conditions (see “Optimal Discharge Checklist for Hospitalists”). HRRP places hospitalists under greater scrutiny for things that happen to their patients after discharge, whether to home or another healthcare facility. In one swoop, the program changed how the healthcare system views care transitions, continuity of care, teamwork, collaboration, and the post-discharge period.

Experts in improving transitions of care—which, it is hoped, would ameliorate the problems that lead to readmissions—emphasize the importance of teamwork across disciplines, specialties, and care settings; dialogue and collaboration between providers; and the formation of community coalitions and integrated systems of care.

Many of the factors that influence the likelihood of readmission are nonmedical, however: socioeconomic status, health literacy, home environment, adherence to prescribed medications, and the ability to make—and keep—follow-up appointments. So, while social variables are an essential part of the readmission conversation, a hospitalist often has no remedy to address—let alone prevent—them.

“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord.”—David J. Yu, MD, MBA, SFHM, medical director, adult inpatient medicine service, Presbyterian Hospital, Albuquerque, N.M.

And therein lies the debate: At what point do hospitalists stop being responsible for discharged patients?

“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord,” says David J. Yu, MD, MBA, FACP, SFHM, medical director of the adult inpatient medicine service at Presbyterian Hospital in Albuquerque, N.M.

Dr. Yu agrees that hospitalists are responsible for the quality of their discharges. Readmissions, he says, are a system issue. Although hospitalists have a responsibility to help drive quality improvement in the hospital, he says it makes little sense to hold the hospitalist responsible for what happens to the patient after discharge.

“I believe that when we talk about hospitalist-staffed post-discharge clinics and things like that, we’re asking the wrong questions,” he says. “We’re turning the hospitalist into a temporary PCP. Those things are only temporary solutions.”

Some hospitalists see this issue as black and white, arguing that their focus should be on caring for “inpatients,” working strictly according to the definition of a hospitalist. They ask a very simple question: How long can responsibility linger once the patient exits our facility?

Others, like Dr. Jha, choose to “own” care transitions into the post-discharge period.

“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job,” Dr. Jha says. “Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge. We follow up on pending lab results. The hospital makes a post-discharge phone call. We’re reachable by phone. We’re still taking care of the patient but in a different way.”

Dr. Jha agrees it’s not reasonable to expect hospitalists to take responsibility for what happens to their patients 30 days after discharge, the standard of such performance models as HRRP.

“But I believe you can push me and my team to step up for a few more days,” he says. “I’ve had patients come back to the hospital the next day. Hey, that means I dropped the ball.”

Yet, the middle ground, from a few days after discharge to 30 days, can seem like an eternity.

“If we think our role completely ends at the time of discharge, what tends to happen is we take our foot off the gas,” says Win Whitcomb, MD, MHM, co-founder of SHM, practicing hospitalist, and CMO of Remedy Partners, a firm specializing in bundled payment programs. “We back off from the patient being discharged and start focusing on the next acutely ill patient who just got admitted.”

“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job. Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge.”—Ashish K. Jha, MD, MPH, K.T. Li Professor of international health, Harvard School of Public Health, director, Harvard Global Health Institute, hospitalist, VA Boston Healthcare System

At a minimum, Dr. Whitcomb says he believes that hospitalists should place a direct phone call to the PCP, preferably before the patient leaves the hospital, although he acknowledges that this is the exception rather than the rule for most hospitalists today.

“You learn things about the patients and their history,” he says, that might be important to the next provider.

Pending lab tests at the time of discharge are another big issue, most experts on readmissions agree. If the hospital doesn’t have a system for ensuring that these results are properly passed on to the next provider of care, the hospitalist group should be spearheading a quality improvement (QI) process to make it happen. Even so, Dr. Whitcomb says hospitalists should not be trying to fix these problems in a vacuum. For example, they should partner with others in the hospital working on readmissions issues and coordinate their post-discharge phone calls to patients with other groups that may be placing similar calls.

“The individual hospitalist is responsible for working with the hospital team to ensure that the patient understands the post-discharge plan of care, that medications are reconciled, and that there is a system for transmitting information to the PCP,” he says.

What Is a Satisfactory Discharge/Handoff?

Experts can agree on one thing: A successful discharge (or handoff) is paramount to preventing what are considered “avoidable” readmissions (see “What We Already Know about Hospital Readmissions”). Exactly what a successful discharge looks like, however, is not as easily defined.

Most agree hospitalists are responsible for making sure that patients understand their condition, treatment plan, what to watch for, and where to go or who to call in a crisis. This means short, digestible, actionable, tailored advice utilizing “teach-back” and other techniques that clarify for the physician whether patients truly understand what they need to know. Some hospitalist groups task a member of the group to be available for the questions that can arise in the first few days after discharge. Some argue hospitalists should provide contact information, even a pager number, to patients going home from the hospital.

Hospitalists should communicate critical information about patient care to the outpatient provider via faxed or e-mailed discharge summaries, phone calls, or other prearranged forms of contact. Breakdowns in this communication have been well documented, as in the 2007 JAMA study that found that only 12% to 34% of discharge summaries had reached the PCP by the time of the first post-discharge medical visit.² Other studies have found that PCPs were not aware of important test results for recently discharged patients roughly 60% of the time, and one in three adult patients discharged from hospital to community didn’t even see a physician within 30 days.^3.4

“Most of this is common sense and courtesy but hard to deliver reliably.”—Gregory Maynard, MD, MSc, SFHM, clinical professor, chief quality officer, University of California Davis Medical Center, Sacramento

Seriously or chronically ill hospitalized patients need help making an appointment for their first post-discharge medical visit; staff should also work with the patient and/or caregiver to make sure they have transportation and can keep that appointment. Patients who don’t have a relationship with a PCP or can’t get an appointment soon enough to forestall potential bounce-backs face an additional challenge.

Some hospitals have developed relationships with community clinics, specialty groups, and other providers who might be able to see the patient more quickly. Others have developed post-discharge clinics on the hospital campus, where the patient can come back for a first follow-up visit with a hospitalist. A medication reconciliation process, drawing upon a best possible medication history conducted within the hospital, is important.

Although it makes sense to try to figure out who needs the most attention, Dr. Maynard says there is no national consensus about the optimal tool for assessing the patient’s risk of rehospitalization. A number of factors considered likely indicators can help focus the team’s attention on those at higher risk, such as patients who are very elderly, have certain diseases like heart failure, take problem-prone medications like warfarin or insulin, have complex medical needs or social circumstances, suffer a lack of financial resources, and have behavioral health overlays.

SHM’s quality improvement toolkit, Project BOOST, offers expert mentored implementation and a variety of other resources to help hospitals get a handle on their care transitions. BOOST now features a readmissions risk assessment tool called the “8Ps”.

SHM has been on record since November 10, 2010, saying that “reducing unnecessary readmissions through improvements in the hospital discharge process is a high priority” for the society and its members, because readmissions are a cost for both the system and the patient—and are often preventable.⁵ Project BOOST is the society’s major contribution to improving care transitions, but SHM also offers other readmissions resources for hospitalists through its Leadership Academy, Quality and Safety Educators Academy, and other QI tools, says Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Hospital in Baltimore and a former SHM president.

Dr. Howell agrees a hospitalist’s responsibility doesn’t end at the hospital door but acknowledges that it is “difficult to say exactly where it ends.”

“I’m not sure we ever end our relationship with our patients, whether they come back to the hospital or not,” he says. “In our practice, we are available to the patient by telephone, with no formal end point.

“I feel more comfortable as a hospitalist with my responsibility ending when I have completed a good handoff to the next provider,” he says, adding that “good handoff” means that the receiving provider acknowledges receiving it and has a chance to ask questions. “There may be information I can provide to the outpatient provider or, if the patient is readmitted, to whomever cares for them next in the hospital.”

Hospitalists have played a key role in highlighting the problems of a fragmented healthcare system, with its inadequate care transitions and follow-up, problems that long preceded the emergence of hospital medicine, Dr. Howell says.

“As a hospitalist, I want my service to try to make the world a better place and to fix the broken incentives that are now in place,” he says. “Whether or not you believe that hospital medicine has introduced its own dyssynchronies on transfers of care, it’s still our responsibility to try to improve the processes.”

Financial Accountability

Healthcare is moving toward integration of services, a process that muddies the waters somewhat when it comes to determining who is accountable for readmissions, says Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy.

“Every one of our members who is actively engaged in integration tells us that not all of those readmissions we might have thought preventable are,” she says, “but they were also surprised at how many we could prevent with better education and communication.”

The new penalties for readmissions are encouraging hospitals do a better job with their care transitions, Foster says. That pressure has helped hospitals to deliver better care, and hospitalists are a “critical piece of the puzzle.”

“When you get patients coming back, analyze what went wrong and reach outside your four walls to other providers,” Foster says. “Those are important opportunities for improvement.”

Rachel George, MD, MBA, SFHM, CPE, now system vice president for Presence Health in Chicago but formerly central business unit president for Brentwood, Tenn.-based Cogent Healthcare, says that when she was at Cogent, the company developed a readmissions playbook for its physicians. Cogent, which was acquired by Seattle’s Sound Physicians late last year, included readmissions in the quality conversations it had with its contracting hospitals, she says, although those conversations varied widely in terms of the resources dedicated to improving care transitions.

“How do you make sure the necessary communication happens?” Dr. George poses. “We believe everybody has a role, but in the hospital, the hospitalist is definitely the captain of the ship.

“It’s not as clear who is the captain of the ship when the patient goes home. Do we need to send someone out to the patient’s house to see what they have in their medicine cabinet?”

Ultimately, she says, it is up to the individual provider to use resources and implement processes that have been developed.

“Cogent always believed in quality as a business strategy, putting part of its payment at risk, but it was not clear that it could use incentives for readmissions rates for individual hospitalists. Hospitals’ incentives are undergoing evolution and are very different than physicians.’”

Randy Ferrance, DC, MD, FAAP, SFHM, medical director of the hospitalist service at Riverside Tappahannock Hospital in rural Virginia, says his hospital recently incorporated readmissions rates into the quality metrics that factor into the five-member hospitalist group’s collective bonus pay.

“The problem with readmissions incentives is who gets assigned the ‘blame,’” he says.

Incorporating readmissions into bonuses and penalties for hospitalist groups is likely to become an increasing trend, says Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. She and partner John Nelson MD, MHM, are seeing that trend “as a bonus component in our clients’ incentive plans, whereas five years ago it was uncommon.”

SHM practice data support this observation, Flores says, with 46.1% of adult medicine hospitalist groups in 2013 reporting the use of readmissions rates as part of performance incentives.⁶

Dr. Nelson, a co-founder of SHM and a longtime practice management columnist for The Hospitalist, says a bonus based on readmissions rates might be reasonable, although it’s important not to create incentives that deny the patient a needed return to the hospital in order to ensure that the hospitalist gets the bonus. Competing pressures on performance for both shorter lengths of stay in the hospital and fewer readmissions complicate incentives for hospitalists. “Compensation incentives [bonuses] based on both length of stay and readmissions are problematic, because they could potentially be construed as incentives to deny needed care, so [they] are best avoided,” Dr. Nelson says.

The Wrong Target?

HRRP has generated a huge amount of commentary in the health policy media. Some charge that it unfairly penalizes teaching hospitals and large institutions, as well as those serving a greater proportion of patients with lower socioeconomic status or those with fewer social supports.⁷

In a New England Journal of Medicine editorial, Dr. Jha and co-author Karen Joynt, MD, MPH, ask “whether the hospital is the appropriate entity to be held accountable for readmissions, given that the events and circumstances that predict readmissions largely take place outside the hospital’s walls.”⁷ Dr. Jha doesn’t consider readmissions rates a true measure of a hospital’s quality.

“I think the real goal should be improving transitions of care—with better quality measures for assessing good transitions,” he says. “You can improve transitions of care without improving readmissions rates.”

A serious disconnect exists between readmissions penalties and evidence for strategies that might be expected to prevent them, says Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Lenox Hill Hospital in New York City and blogger for The Hospital Leader.

“As much as we might be held accountable for certain outcomes like readmissions, the reality is we can’t control them,” he says. “There are so many other factors out there that we don’t know about. Is the readmissions rate a good proxy for quality? We’ve seen evidence that it doesn’t relate very well to mortality rates.”⁸

Assessing blame can be a slippery slope, some experts say.

“My first message to my hospitalist colleagues—myself included—is to try to stop reacting as if this were about individual blame for the discharging hospitalist,” says Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies, who practices HM at Newton-Wellesley Hospital in Newton, Mass. “Certainly, that’s not how CMS views it. They are incentivizing hospitals and providers to improve systems of care and provide new and better types of continuing care.”

Dr. Boutwell, who is also an attending physician at Massachusetts General Hospital in Boston, sees the good in programs such as HRRP.

“[The program] has done a good job of mobilizing resources where previously very little attention had been given,” she says. “It aimed to catalyze investments in readmissions reduction, and that has occurred.”

Often, when hospitalists don’t do an “adequate job” of preparing their patients for discharges, including failures in communicating with outpatient providers, patients are in a catch-22.

“In many cases the PCP may tell the patient, ‘I don’t know enough about your case. I need you to go back to the hospital,’” Dr. Boutwell says. “That’s a big part of what we’re trying to avoid.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368(13):1175-1177.
2. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
3. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-128.
4. Sommers A, Cunningham PJ. Physician visits after hospital discharge: implications for reducing readmissions. National Institute for Health Care Reform Research Brief No. 6. December 2011. Available at: http://www.nihcr.org/Reducing_Readmissions.html. Accessed March 12, 2015.
5. Society of Hospital Medicine. Reducing readmissions and improving care transitions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=27513. Accessed March 12, 2015.
6. Society of Hospital Medicine. 2014 State of Hospital Medicine Report. September 5, 2014. Philadelphia: Society of Hospital Medicine; 2014:84.
7. Abelson R. Hospitals question Medicare rules on readmissions. The New York Times. March 29, 2013. Available at: http://www.nytimes.com/2013/03/30/business/hospitals-question-fairness-of-new-medicare-rules.html. Accessed March 12, 2015.
8. Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-593.

A widely cited statistic in the national readmissions debate holds that one in five acute hospital discharges will lead to a readmission within 30 days.¹ Associated costs are estimated at $17.5 billion, although that figure encapsulates significant variation across diagnoses, regions, and hospital models.¹ Analyses by CMS and others suggest that average 30-day readmission rates have been falling, albeit slowly, to 17.8% during the fourth quarter of 2012 after averaging 19% over the previous five years, according to Congressional testimony by Medicare Director Jonathan Blum in February 2013.²

CMS calculates “excessive readmissions rates” for subsequent hospital admissions to the same or a different hospital for specific diagnoses within 30 days of discharge, risk-adjusted for planned and unrelated readmissions using methodology endorsed by the National Quality Forum. Based on the hospital’s rate of actual to expected readmissions, HRRP penalties are applied to all Medicare-based diagnosis-related group (DRG) payments to the hospital for the fiscal year in question, to a maximum of 3% of Medicare payments. The list of conditions now includes heart failure, acute myocardial infarction, pneumonia, acute exacerbation of COPD, other lung ailments such as chronic bronchitis, and admissions for elective total hip and total knee arthroplasty.

Aggregate average penalty in FY2015 for 2,610 hospitals paying penalties, or three-fourths of those subject to the program, will be 0.63% of total base hospital DRG reimbursement, or approximately $428 million in total readmissions penalties. Thirty-nine hospitals are paying the full 3% penalty, based on their posted readmissions between July 2010 and June 2013.³ If a hospital has fewer than 25 discharges for a given condition, then CMS does not calculate its excess readmissions penalty for that condition.

In its June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC), which first proposed readmissions payment incentives in 2008, recommended steps to refine the computation of penalties, all with “the goal that any policy change should maintain a hospital’s incentive to reduce readmissions.”⁴ CMS has stated that it is continuing to revise its algorithms for excluding planned and unrelated readmissions from the penalty calculation.⁵

MedPAC found that the rate of “potentially preventable readmissions” (PPR) was 12.3% in 2011, according to the “3M Algorithm” developed by 3M Health Information Systems, which uses administrative data to identify hospital readmissions that may indicate problems with quality of care. The PPR logic determines whether the reason for readmission is clinically related to a prior admission and therefore potentially preventable.⁶

Others define preventable readmissions in terms of quality problems, medical errors through actions taken or omitted during the initial hospital stay that could lead to patient harm.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
2. Blum J. Statement of Jonathan Blum on delivery system reform: progress report from CMS before the U.S. Senate Finance Committee. February 28, 2013. Available at: http://www.finance.senate.gov/imo/media/doc/CMS%20Delivery%20System%20Reform%20Testimony%202.28.13%20(J.%20Blum).pdf. Accessed March 12, 2015.
3. Rau J. Medicare Fines 2,610 Hospitals in Third Round of Readmissions Penalties. Kaiser Health News. October 2, 2014. Available at: http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/. Accessed March 12, 2015.
4. Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system. Chapter 4: refining the hospital readmissions reduction program. June 2013. Available at: http://www.medpac.gov/documents/reports/jun13_entirereport.pdf. Accessed March 12, 2015.
5. Rodak S. CMS responds to 6 major critiques of readmissions measures. Becker’s Infection Control and Clinical Quality. August 7, 2013. Available at: http://www.beckershospitalreview.com/quality/cms-responds-to-6-major-critiques-of-readmission-measure.html. Accessed March 12 2015.
6. Goldfield NI, McCullough EC, Hughes JS, et al. Identifying potentially preventable readmissions. Healthcare Financing Review. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/08Fallpg75.pdf. Accessed March 12, 2015.

A widely cited statistic in the national readmissions debate holds that one in five acute hospital discharges will lead to a readmission within 30 days.¹ Associated costs are estimated at $17.5 billion, although that figure encapsulates significant variation across diagnoses, regions, and hospital models.¹ Analyses by CMS and others suggest that average 30-day readmission rates have been falling, albeit slowly, to 17.8% during the fourth quarter of 2012 after averaging 19% over the previous five years, according to Congressional testimony by Medicare Director Jonathan Blum in February 2013.²

CMS calculates “excessive readmissions rates” for subsequent hospital admissions to the same or a different hospital for specific diagnoses within 30 days of discharge, risk-adjusted for planned and unrelated readmissions using methodology endorsed by the National Quality Forum. Based on the hospital’s rate of actual to expected readmissions, HRRP penalties are applied to all Medicare-based diagnosis-related group (DRG) payments to the hospital for the fiscal year in question, to a maximum of 3% of Medicare payments. The list of conditions now includes heart failure, acute myocardial infarction, pneumonia, acute exacerbation of COPD, other lung ailments such as chronic bronchitis, and admissions for elective total hip and total knee arthroplasty.

Aggregate average penalty in FY2015 for 2,610 hospitals paying penalties, or three-fourths of those subject to the program, will be 0.63% of total base hospital DRG reimbursement, or approximately $428 million in total readmissions penalties. Thirty-nine hospitals are paying the full 3% penalty, based on their posted readmissions between July 2010 and June 2013.³ If a hospital has fewer than 25 discharges for a given condition, then CMS does not calculate its excess readmissions penalty for that condition.

In its June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC), which first proposed readmissions payment incentives in 2008, recommended steps to refine the computation of penalties, all with “the goal that any policy change should maintain a hospital’s incentive to reduce readmissions.”⁴ CMS has stated that it is continuing to revise its algorithms for excluding planned and unrelated readmissions from the penalty calculation.⁵

MedPAC found that the rate of “potentially preventable readmissions” (PPR) was 12.3% in 2011, according to the “3M Algorithm” developed by 3M Health Information Systems, which uses administrative data to identify hospital readmissions that may indicate problems with quality of care. The PPR logic determines whether the reason for readmission is clinically related to a prior admission and therefore potentially preventable.⁶

Others define preventable readmissions in terms of quality problems, medical errors through actions taken or omitted during the initial hospital stay that could lead to patient harm.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
2. Blum J. Statement of Jonathan Blum on delivery system reform: progress report from CMS before the U.S. Senate Finance Committee. February 28, 2013. Available at: http://www.finance.senate.gov/imo/media/doc/CMS%20Delivery%20System%20Reform%20Testimony%202.28.13%20(J.%20Blum).pdf. Accessed March 12, 2015.
3. Rau J. Medicare Fines 2,610 Hospitals in Third Round of Readmissions Penalties. Kaiser Health News. October 2, 2014. Available at: http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/. Accessed March 12, 2015.
4. Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system. Chapter 4: refining the hospital readmissions reduction program. June 2013. Available at: http://www.medpac.gov/documents/reports/jun13_entirereport.pdf. Accessed March 12, 2015.
5. Rodak S. CMS responds to 6 major critiques of readmissions measures. Becker’s Infection Control and Clinical Quality. August 7, 2013. Available at: http://www.beckershospitalreview.com/quality/cms-responds-to-6-major-critiques-of-readmission-measure.html. Accessed March 12 2015.
6. Goldfield NI, McCullough EC, Hughes JS, et al. Identifying potentially preventable readmissions. Healthcare Financing Review. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/08Fallpg75.pdf. Accessed March 12, 2015.

A widely cited statistic in the national readmissions debate holds that one in five acute hospital discharges will lead to a readmission within 30 days.¹ Associated costs are estimated at $17.5 billion, although that figure encapsulates significant variation across diagnoses, regions, and hospital models.¹ Analyses by CMS and others suggest that average 30-day readmission rates have been falling, albeit slowly, to 17.8% during the fourth quarter of 2012 after averaging 19% over the previous five years, according to Congressional testimony by Medicare Director Jonathan Blum in February 2013.²

CMS calculates “excessive readmissions rates” for subsequent hospital admissions to the same or a different hospital for specific diagnoses within 30 days of discharge, risk-adjusted for planned and unrelated readmissions using methodology endorsed by the National Quality Forum. Based on the hospital’s rate of actual to expected readmissions, HRRP penalties are applied to all Medicare-based diagnosis-related group (DRG) payments to the hospital for the fiscal year in question, to a maximum of 3% of Medicare payments. The list of conditions now includes heart failure, acute myocardial infarction, pneumonia, acute exacerbation of COPD, other lung ailments such as chronic bronchitis, and admissions for elective total hip and total knee arthroplasty.

Aggregate average penalty in FY2015 for 2,610 hospitals paying penalties, or three-fourths of those subject to the program, will be 0.63% of total base hospital DRG reimbursement, or approximately $428 million in total readmissions penalties. Thirty-nine hospitals are paying the full 3% penalty, based on their posted readmissions between July 2010 and June 2013.³ If a hospital has fewer than 25 discharges for a given condition, then CMS does not calculate its excess readmissions penalty for that condition.

In its June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC), which first proposed readmissions payment incentives in 2008, recommended steps to refine the computation of penalties, all with “the goal that any policy change should maintain a hospital’s incentive to reduce readmissions.”⁴ CMS has stated that it is continuing to revise its algorithms for excluding planned and unrelated readmissions from the penalty calculation.⁵

MedPAC found that the rate of “potentially preventable readmissions” (PPR) was 12.3% in 2011, according to the “3M Algorithm” developed by 3M Health Information Systems, which uses administrative data to identify hospital readmissions that may indicate problems with quality of care. The PPR logic determines whether the reason for readmission is clinically related to a prior admission and therefore potentially preventable.⁶

Others define preventable readmissions in terms of quality problems, medical errors through actions taken or omitted during the initial hospital stay that could lead to patient harm.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
2. Blum J. Statement of Jonathan Blum on delivery system reform: progress report from CMS before the U.S. Senate Finance Committee. February 28, 2013. Available at: http://www.finance.senate.gov/imo/media/doc/CMS%20Delivery%20System%20Reform%20Testimony%202.28.13%20(J.%20Blum).pdf. Accessed March 12, 2015.
3. Rau J. Medicare Fines 2,610 Hospitals in Third Round of Readmissions Penalties. Kaiser Health News. October 2, 2014. Available at: http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/. Accessed March 12, 2015.
4. Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system. Chapter 4: refining the hospital readmissions reduction program. June 2013. Available at: http://www.medpac.gov/documents/reports/jun13_entirereport.pdf. Accessed March 12, 2015.
5. Rodak S. CMS responds to 6 major critiques of readmissions measures. Becker’s Infection Control and Clinical Quality. August 7, 2013. Available at: http://www.beckershospitalreview.com/quality/cms-responds-to-6-major-critiques-of-readmission-measure.html. Accessed March 12 2015.
6. Goldfield NI, McCullough EC, Hughes JS, et al. Identifying potentially preventable readmissions. Healthcare Financing Review. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/08Fallpg75.pdf. Accessed March 12, 2015.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

Larry Beresford is a freelance writer in Alameda, Calif.

This month, our cover story focuses on how hospitalists fit into the readmission prevention framework. Hospitalist Dr. Eric Howell discusses the ongoing problem of hospital discharges and sees preventing readmissions as a way to fix it. Also on our cover, endocrinologists share 10 things hospitalists need to know about treating endocrine disease. In addition this month, hospital medicine leader Dr. Bob Wachter shares insights on his new book, “The Digital Doctor.”

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/03/The-Hospitalist-Highlights-April-2015.mp3"][/audio]

This month, our cover story focuses on how hospitalists fit into the readmission prevention framework. Hospitalist Dr. Eric Howell discusses the ongoing problem of hospital discharges and sees preventing readmissions as a way to fix it. Also on our cover, endocrinologists share 10 things hospitalists need to know about treating endocrine disease. In addition this month, hospital medicine leader Dr. Bob Wachter shares insights on his new book, “The Digital Doctor.”

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/03/The-Hospitalist-Highlights-April-2015.mp3"][/audio]

This month, our cover story focuses on how hospitalists fit into the readmission prevention framework. Hospitalist Dr. Eric Howell discusses the ongoing problem of hospital discharges and sees preventing readmissions as a way to fix it. Also on our cover, endocrinologists share 10 things hospitalists need to know about treating endocrine disease. In addition this month, hospital medicine leader Dr. Bob Wachter shares insights on his new book, “The Digital Doctor.”

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/03/The-Hospitalist-Highlights-April-2015.mp3"][/audio]

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.³

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”

Tom Collins is a freelance writer in South Florida.

Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.⁴ Don’t fall into the trap, endocrinologists say.³

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.³

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”

Tom Collins is a freelance writer in South Florida.

Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.⁴ Don’t fall into the trap, endocrinologists say.³

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.³

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”

Tom Collins is a freelance writer in South Florida.

Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.⁴ Don’t fall into the trap, endocrinologists say.³

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

A new guide on the use of medications to treat patients with alcohol use disorder has been released by the Substance Abuse and Mental Health Services Administration in conjunction with National Alcohol Awareness Month.

The guide provides an overview of four Food and Drug Administration–approved drugs developed to treat alcohol use disorder: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate. It also discusses how to screen, treat, and monitor patients based on their individual needs.

“Current evidence shows that medications are underused in the treatment of alcohol use disorder,” the agency said in a statement announcing the new guidance. “As the Patient Protection and Affordable Care Act (ACA) continues to be implemented, there is considerable potential for expanding use of medication-assisted treatment to treat alcohol use disorder,” they concluded.

The guide can be found online at http://store.samhsa.gov.

A new guide on the use of medications to treat patients with alcohol use disorder has been released by the Substance Abuse and Mental Health Services Administration in conjunction with National Alcohol Awareness Month.

The guide provides an overview of four Food and Drug Administration–approved drugs developed to treat alcohol use disorder: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate. It also discusses how to screen, treat, and monitor patients based on their individual needs.

“Current evidence shows that medications are underused in the treatment of alcohol use disorder,” the agency said in a statement announcing the new guidance. “As the Patient Protection and Affordable Care Act (ACA) continues to be implemented, there is considerable potential for expanding use of medication-assisted treatment to treat alcohol use disorder,” they concluded.

The guide can be found online at http://store.samhsa.gov.

A new guide on the use of medications to treat patients with alcohol use disorder has been released by the Substance Abuse and Mental Health Services Administration in conjunction with National Alcohol Awareness Month.

The guide provides an overview of four Food and Drug Administration–approved drugs developed to treat alcohol use disorder: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate. It also discusses how to screen, treat, and monitor patients based on their individual needs.

“Current evidence shows that medications are underused in the treatment of alcohol use disorder,” the agency said in a statement announcing the new guidance. “As the Patient Protection and Affordable Care Act (ACA) continues to be implemented, there is considerable potential for expanding use of medication-assisted treatment to treat alcohol use disorder,” they concluded.

The guide can be found online at http://store.samhsa.gov.

It’s not uncommon to read about neurologists of yore and be stunned, if not horrified, to think of what they had to work with.

Going back perhaps 100 years, it wasn’t uncommon for anyone with a head injury and hemiparesis to have one (or more) burr holes placed in hope of draining a subdural hematoma causing the symptoms.

In more recent memory was the dreaded ventriculogram, or pneumoencephalogram: A painful procedure in which a lumbar puncture was done in order to blow air bubbles into the spinal fluid, then use skull X-rays to watch them outline the ventricles and other structures to look for midline shift.

I remember one of my old teachers (RIP, Al) recalling that imaging in his younger era consisted of a cerebral angiogram to look for displaced vessels and an EEG for focal slowing.

The CT scan obviously changed all that, with its excellent noninvasive imaging of the brain, and the MRI made things even better by several orders of magnitude.

But where are we now? As frightening as the practices of 50-100 years ago may seem now, we have to keep in mind that, to the doctors using them, they were at the cutting edge of medical technology. They weren’t saying “this would be so much easier if the MRI had been invented.”

None of us can clearly see what the next big advances will be. We use what we have, knowing it’s the best we can do. As the leading philosopher of our era (Yogi Berra) said, “It’s tough to make predictions, especially about the future.”

So what will future doctors think of us? What tests will they look at and shudder, asking, “They actually DID that to people?”

I’m sure the CT-myelogram will be one of them. It is perhaps the last descendant of the pneumoencephalogram still in use; it’s done uncommonly, but still has value. For those who can’t have an MRI or where confirmation of an MRI is needed, it’s quite accurate.

What other tests will be considered archaic? The EMG/NCV [electromyogram and nerve conduction studies]? Lumbar puncture? Cerebral angiogram?

Of course, these are just in neurology. Every field is going to have a past test that today is looked upon with horror, and the knowledge that someday another generation will look at us the same way.

Like all scientific disciplines, what we do is based on the foundation laid by those before us, and it’s up to the next generation to push the horizon further back.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

It’s not uncommon to read about neurologists of yore and be stunned, if not horrified, to think of what they had to work with.

Going back perhaps 100 years, it wasn’t uncommon for anyone with a head injury and hemiparesis to have one (or more) burr holes placed in hope of draining a subdural hematoma causing the symptoms.

In more recent memory was the dreaded ventriculogram, or pneumoencephalogram: A painful procedure in which a lumbar puncture was done in order to blow air bubbles into the spinal fluid, then use skull X-rays to watch them outline the ventricles and other structures to look for midline shift.

I remember one of my old teachers (RIP, Al) recalling that imaging in his younger era consisted of a cerebral angiogram to look for displaced vessels and an EEG for focal slowing.

The CT scan obviously changed all that, with its excellent noninvasive imaging of the brain, and the MRI made things even better by several orders of magnitude.

But where are we now? As frightening as the practices of 50-100 years ago may seem now, we have to keep in mind that, to the doctors using them, they were at the cutting edge of medical technology. They weren’t saying “this would be so much easier if the MRI had been invented.”

None of us can clearly see what the next big advances will be. We use what we have, knowing it’s the best we can do. As the leading philosopher of our era (Yogi Berra) said, “It’s tough to make predictions, especially about the future.”

So what will future doctors think of us? What tests will they look at and shudder, asking, “They actually DID that to people?”

I’m sure the CT-myelogram will be one of them. It is perhaps the last descendant of the pneumoencephalogram still in use; it’s done uncommonly, but still has value. For those who can’t have an MRI or where confirmation of an MRI is needed, it’s quite accurate.

What other tests will be considered archaic? The EMG/NCV [electromyogram and nerve conduction studies]? Lumbar puncture? Cerebral angiogram?

Of course, these are just in neurology. Every field is going to have a past test that today is looked upon with horror, and the knowledge that someday another generation will look at us the same way.

Like all scientific disciplines, what we do is based on the foundation laid by those before us, and it’s up to the next generation to push the horizon further back.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

It’s not uncommon to read about neurologists of yore and be stunned, if not horrified, to think of what they had to work with.

Going back perhaps 100 years, it wasn’t uncommon for anyone with a head injury and hemiparesis to have one (or more) burr holes placed in hope of draining a subdural hematoma causing the symptoms.

In more recent memory was the dreaded ventriculogram, or pneumoencephalogram: A painful procedure in which a lumbar puncture was done in order to blow air bubbles into the spinal fluid, then use skull X-rays to watch them outline the ventricles and other structures to look for midline shift.

I remember one of my old teachers (RIP, Al) recalling that imaging in his younger era consisted of a cerebral angiogram to look for displaced vessels and an EEG for focal slowing.

The CT scan obviously changed all that, with its excellent noninvasive imaging of the brain, and the MRI made things even better by several orders of magnitude.

But where are we now? As frightening as the practices of 50-100 years ago may seem now, we have to keep in mind that, to the doctors using them, they were at the cutting edge of medical technology. They weren’t saying “this would be so much easier if the MRI had been invented.”

None of us can clearly see what the next big advances will be. We use what we have, knowing it’s the best we can do. As the leading philosopher of our era (Yogi Berra) said, “It’s tough to make predictions, especially about the future.”

So what will future doctors think of us? What tests will they look at and shudder, asking, “They actually DID that to people?”

I’m sure the CT-myelogram will be one of them. It is perhaps the last descendant of the pneumoencephalogram still in use; it’s done uncommonly, but still has value. For those who can’t have an MRI or where confirmation of an MRI is needed, it’s quite accurate.

What other tests will be considered archaic? The EMG/NCV [electromyogram and nerve conduction studies]? Lumbar puncture? Cerebral angiogram?

Of course, these are just in neurology. Every field is going to have a past test that today is looked upon with horror, and the knowledge that someday another generation will look at us the same way.

Like all scientific disciplines, what we do is based on the foundation laid by those before us, and it’s up to the next generation to push the horizon further back.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Summary: Delirium is a common problem in hospitalized patients, and all too often delirium is iatrogenic. Delirium is associated with poor outcomes such as prolonged hospitalization and functional decline, and it increases the risk of nursing home admission. The most common tool to assess the presence of delirium is the Confusion Assessment Method (CAM). Dr. Cumbler educated the audience on a more refined tool, the 3D CAM [PDF], and provided the algorithm for diagnosis and evaluation of hospital-onset delirium.

Where delirium is concerned (as with most conditions), “an ounce of prevention is worth a pound of cure.” Namely, avoid prescribing problem medications such as anticholinergics, sedative/hypnotics (except benzodiazepines for treatment of alcohol withdrawal), and antihistamines; and minimize narcotics, but don’t undertreat pain as uncontrolled pain is a more potent delirium trigger than narcotics.

Avoid sleep deprivation. Do we really require vital signs and phlebotomy between midnight and 6 a.m.? Make sure patients have their glasses and hearing aids, and keep them up and moving during daylight hours. Sleep and sensory deprivation are effective forms of human torture and are known to be rather disorienting.

Finally, antipsychotics are associated with increased mortality in dementia. Patients with agitated delirium may benefit from a low dose of haloperidol. When prescribing haloperidol, remember IV administration requires EKG monitoring (FDA black box warning), and a reasonable starting dose is 0.5 mg, NOT 5 mg.

HM takeaways:

• Use CAM, 3D CAM to diagnose delirium;
• Avoid anticholinergic medications (promethazine, cyclobenzaprine, oxybutynin, amitriptyline, prednisolone, theophylline, dixogin, furosemide);
• Minimize, but do not avoid, narcotics in patients with both pain and delirium;
• Use low-dose antipsychotics, not benzodiazepines, for agitated delirium; and
• STOP antipsychotics ASAP, ideally prior to discharge; if not prior to discharge, then include discontinuation date on discharge medication list. TH

Summary: Delirium is a common problem in hospitalized patients, and all too often delirium is iatrogenic. Delirium is associated with poor outcomes such as prolonged hospitalization and functional decline, and it increases the risk of nursing home admission. The most common tool to assess the presence of delirium is the Confusion Assessment Method (CAM). Dr. Cumbler educated the audience on a more refined tool, the 3D CAM [PDF], and provided the algorithm for diagnosis and evaluation of hospital-onset delirium.

Where delirium is concerned (as with most conditions), “an ounce of prevention is worth a pound of cure.” Namely, avoid prescribing problem medications such as anticholinergics, sedative/hypnotics (except benzodiazepines for treatment of alcohol withdrawal), and antihistamines; and minimize narcotics, but don’t undertreat pain as uncontrolled pain is a more potent delirium trigger than narcotics.

Avoid sleep deprivation. Do we really require vital signs and phlebotomy between midnight and 6 a.m.? Make sure patients have their glasses and hearing aids, and keep them up and moving during daylight hours. Sleep and sensory deprivation are effective forms of human torture and are known to be rather disorienting.

Finally, antipsychotics are associated with increased mortality in dementia. Patients with agitated delirium may benefit from a low dose of haloperidol. When prescribing haloperidol, remember IV administration requires EKG monitoring (FDA black box warning), and a reasonable starting dose is 0.5 mg, NOT 5 mg.

HM takeaways:

• Use CAM, 3D CAM to diagnose delirium;
• Avoid anticholinergic medications (promethazine, cyclobenzaprine, oxybutynin, amitriptyline, prednisolone, theophylline, dixogin, furosemide);
• Minimize, but do not avoid, narcotics in patients with both pain and delirium;
• Use low-dose antipsychotics, not benzodiazepines, for agitated delirium; and
• STOP antipsychotics ASAP, ideally prior to discharge; if not prior to discharge, then include discontinuation date on discharge medication list. TH

Summary: Delirium is a common problem in hospitalized patients, and all too often delirium is iatrogenic. Delirium is associated with poor outcomes such as prolonged hospitalization and functional decline, and it increases the risk of nursing home admission. The most common tool to assess the presence of delirium is the Confusion Assessment Method (CAM). Dr. Cumbler educated the audience on a more refined tool, the 3D CAM [PDF], and provided the algorithm for diagnosis and evaluation of hospital-onset delirium.

Where delirium is concerned (as with most conditions), “an ounce of prevention is worth a pound of cure.” Namely, avoid prescribing problem medications such as anticholinergics, sedative/hypnotics (except benzodiazepines for treatment of alcohol withdrawal), and antihistamines; and minimize narcotics, but don’t undertreat pain as uncontrolled pain is a more potent delirium trigger than narcotics.

Avoid sleep deprivation. Do we really require vital signs and phlebotomy between midnight and 6 a.m.? Make sure patients have their glasses and hearing aids, and keep them up and moving during daylight hours. Sleep and sensory deprivation are effective forms of human torture and are known to be rather disorienting.

Finally, antipsychotics are associated with increased mortality in dementia. Patients with agitated delirium may benefit from a low dose of haloperidol. When prescribing haloperidol, remember IV administration requires EKG monitoring (FDA black box warning), and a reasonable starting dose is 0.5 mg, NOT 5 mg.

HM takeaways:

• Use CAM, 3D CAM to diagnose delirium;
• Avoid anticholinergic medications (promethazine, cyclobenzaprine, oxybutynin, amitriptyline, prednisolone, theophylline, dixogin, furosemide);
• Minimize, but do not avoid, narcotics in patients with both pain and delirium;
• Use low-dose antipsychotics, not benzodiazepines, for agitated delirium; and
• STOP antipsychotics ASAP, ideally prior to discharge; if not prior to discharge, then include discontinuation date on discharge medication list. TH