Clinical question: Do fibrinolytics decrease mortality rates in intermediate-risk pulmonary emboli?

Background: Over the past 40 years, fibrinolytics have been studied in fewer than 1,000 patients with pulmonary emboli. Previous studies have shown improvement in hemodynamic response, though the evidence for clinical outcomes such as death and hemodynamic collapse have not been studied adequately in intermediate-risk pulmonary emboli.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Seventy-six sites in 13 countries.

Synopsis: The PEITHO [Pulmonary EmbolIsm THrOmbolysis] trial randomized 1,006 patients in a double-blind fashion. All patients had acute pulmonary emboli with evidence of right ventricular dysfunction on computed tomography scan or echocardiogram, as well as an elevated troponin, in the absence of hemodynamic compromise. Patients received tenecteplase and heparin or placebo and heparin. The primary outcome was death and hemodynamic decompensation.

The primary outcome was found in 2.6% of the treatment group and 5.6% in the placebo group (P=0.02), favoring the treatment group; however, there was no difference in death at seven days (1.2% vs. 1.8%; P=0.42) and 30 days (2.4% vs. 3.2%; P=0.42). Additionally, there were higher rates of extracranial bleeding (6.3% vs. 1.2%; P=<0.001) and stroke (2.4% vs. 0.2%; P=0.003) in the tenecteplase group than in the placebo group. Of the 12 strokes in the treatment group, 11 were hemorrhagic.

Bottom line: Treatment of intermediate-risk pulmonary emboli with fibrinolytics may improve hemodynamics; however, there is no mortality benefit, and fibrinolytic therapy carries an increased risk of bleeding and stroke.

Citation: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411.

Clinical question: Do fibrinolytics decrease mortality rates in intermediate-risk pulmonary emboli?

Background: Over the past 40 years, fibrinolytics have been studied in fewer than 1,000 patients with pulmonary emboli. Previous studies have shown improvement in hemodynamic response, though the evidence for clinical outcomes such as death and hemodynamic collapse have not been studied adequately in intermediate-risk pulmonary emboli.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Seventy-six sites in 13 countries.

Synopsis: The PEITHO [Pulmonary EmbolIsm THrOmbolysis] trial randomized 1,006 patients in a double-blind fashion. All patients had acute pulmonary emboli with evidence of right ventricular dysfunction on computed tomography scan or echocardiogram, as well as an elevated troponin, in the absence of hemodynamic compromise. Patients received tenecteplase and heparin or placebo and heparin. The primary outcome was death and hemodynamic decompensation.

The primary outcome was found in 2.6% of the treatment group and 5.6% in the placebo group (P=0.02), favoring the treatment group; however, there was no difference in death at seven days (1.2% vs. 1.8%; P=0.42) and 30 days (2.4% vs. 3.2%; P=0.42). Additionally, there were higher rates of extracranial bleeding (6.3% vs. 1.2%; P=<0.001) and stroke (2.4% vs. 0.2%; P=0.003) in the tenecteplase group than in the placebo group. Of the 12 strokes in the treatment group, 11 were hemorrhagic.

Bottom line: Treatment of intermediate-risk pulmonary emboli with fibrinolytics may improve hemodynamics; however, there is no mortality benefit, and fibrinolytic therapy carries an increased risk of bleeding and stroke.

Citation: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411.

Clinical question: Do fibrinolytics decrease mortality rates in intermediate-risk pulmonary emboli?

Background: Over the past 40 years, fibrinolytics have been studied in fewer than 1,000 patients with pulmonary emboli. Previous studies have shown improvement in hemodynamic response, though the evidence for clinical outcomes such as death and hemodynamic collapse have not been studied adequately in intermediate-risk pulmonary emboli.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Seventy-six sites in 13 countries.

Synopsis: The PEITHO [Pulmonary EmbolIsm THrOmbolysis] trial randomized 1,006 patients in a double-blind fashion. All patients had acute pulmonary emboli with evidence of right ventricular dysfunction on computed tomography scan or echocardiogram, as well as an elevated troponin, in the absence of hemodynamic compromise. Patients received tenecteplase and heparin or placebo and heparin. The primary outcome was death and hemodynamic decompensation.

The primary outcome was found in 2.6% of the treatment group and 5.6% in the placebo group (P=0.02), favoring the treatment group; however, there was no difference in death at seven days (1.2% vs. 1.8%; P=0.42) and 30 days (2.4% vs. 3.2%; P=0.42). Additionally, there were higher rates of extracranial bleeding (6.3% vs. 1.2%; P=<0.001) and stroke (2.4% vs. 0.2%; P=0.003) in the tenecteplase group than in the placebo group. Of the 12 strokes in the treatment group, 11 were hemorrhagic.

Bottom line: Treatment of intermediate-risk pulmonary emboli with fibrinolytics may improve hemodynamics; however, there is no mortality benefit, and fibrinolytic therapy carries an increased risk of bleeding and stroke.

Citation: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411.

Clinical question: What new recommendations are made in the AHA/ACC/HRS atrial fibrillation guidelines?

Background: This is the AHA’s first comprehensive update on atrial fibrillation since 2006; there were two intervening focused updates in 2011.

Synopsis: The majority of the new recommendations center on patient selection for anticoagulation and the role of the new oral anticoagulants.

CHA2DS2-VASc is now recommended over CHADS2 for evaluation of stroke risk, with anticoagulation recommended for a score of two or greater, or for a patient with any prior history of stroke or transient ischemic attack.

Warfarin, direct thrombin inhibitors, or factor Xa inhibitors may be considered in patients with normal renal function. Reduced doses of these medications may be considered in patients with moderate to severe renal dysfunction but have not been studied in clinical trials.

Warfarin remains the drug of choice for patients on hemodialysis and those with hemodynamically significant mitral stenosis or aortic valve replacement.

The clinical utility of bleeding risk scores remains insufficient for formal recommendations. There is sparse evidence on which to base recommendations for bridging, but additional studies, such as the BRIDGE trial, are ongoing. A liberal rate control strategy targeting heart rates <110 in asymptomatic patients with preserved systolic function is reasonable; ideal rate control targets remain controversial.

Citation: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online ahead of print April 10, 2014]. Circulation.

Clinical question: What new recommendations are made in the AHA/ACC/HRS atrial fibrillation guidelines?

Background: This is the AHA’s first comprehensive update on atrial fibrillation since 2006; there were two intervening focused updates in 2011.

Synopsis: The majority of the new recommendations center on patient selection for anticoagulation and the role of the new oral anticoagulants.

CHA2DS2-VASc is now recommended over CHADS2 for evaluation of stroke risk, with anticoagulation recommended for a score of two or greater, or for a patient with any prior history of stroke or transient ischemic attack.

Warfarin, direct thrombin inhibitors, or factor Xa inhibitors may be considered in patients with normal renal function. Reduced doses of these medications may be considered in patients with moderate to severe renal dysfunction but have not been studied in clinical trials.

Warfarin remains the drug of choice for patients on hemodialysis and those with hemodynamically significant mitral stenosis or aortic valve replacement.

The clinical utility of bleeding risk scores remains insufficient for formal recommendations. There is sparse evidence on which to base recommendations for bridging, but additional studies, such as the BRIDGE trial, are ongoing. A liberal rate control strategy targeting heart rates <110 in asymptomatic patients with preserved systolic function is reasonable; ideal rate control targets remain controversial.

Citation: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online ahead of print April 10, 2014]. Circulation.

Clinical question: What new recommendations are made in the AHA/ACC/HRS atrial fibrillation guidelines?

Background: This is the AHA’s first comprehensive update on atrial fibrillation since 2006; there were two intervening focused updates in 2011.

Synopsis: The majority of the new recommendations center on patient selection for anticoagulation and the role of the new oral anticoagulants.

CHA2DS2-VASc is now recommended over CHADS2 for evaluation of stroke risk, with anticoagulation recommended for a score of two or greater, or for a patient with any prior history of stroke or transient ischemic attack.

Warfarin, direct thrombin inhibitors, or factor Xa inhibitors may be considered in patients with normal renal function. Reduced doses of these medications may be considered in patients with moderate to severe renal dysfunction but have not been studied in clinical trials.

Warfarin remains the drug of choice for patients on hemodialysis and those with hemodynamically significant mitral stenosis or aortic valve replacement.

The clinical utility of bleeding risk scores remains insufficient for formal recommendations. There is sparse evidence on which to base recommendations for bridging, but additional studies, such as the BRIDGE trial, are ongoing. A liberal rate control strategy targeting heart rates <110 in asymptomatic patients with preserved systolic function is reasonable; ideal rate control targets remain controversial.

Citation: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online ahead of print April 10, 2014]. Circulation.

Clinical question: Does peri-operative clonidine prevent myocardial infarction (MI)?

Background: A meta-analysis showed that peri-operative clonidine decreased death and MI compared to placebo in patients undergoing vascular surgery. It also showed that rates of death and MI were the same for patients taking clonidine vs. placebo undergoing nonvascular surgery without significant effects on hemodynamics.

Study design: Randomized controlled trial.

Setting: One hundred thirty-five centers across 23 countries.

Synopsis: The POISE-II [PeriOperative Ischemic Evaluation-II] study randomized 10,010 patients in a 1:1:1:1 fashion to analyze peri-operative clonidine and aspirin against placebo. This paper specifically examined the effects of peri-operative clonidine vs. placebo. The average age of the population was 69 years old. The most common comorbidities were diabetes (38%) and coronary artery disease (23%).

The outcomes showed that clonidine vs. placebo yielded insignificant results with respect to the primary endpoints (death, MI, or stroke: 7.6% vs. 7.0%; P=0.30); however, there were significantly higher rates of clinically significant hypotension (47.6% vs. 37.1%; P<0.001), bradycardia (12.0% vs. 8.1%; P<0.001), and nonfatal cardiac arrest (0.3% vs. 0.1%; P=0.02) in the clonidine group.

These results differ from previous, smaller studies, which suggested that there were no significant hemodynamic changes when patients received peri-operative clonidine.

Bottom line: Peri-operative clonidine does not affect the rate of MI but increases clinically significant hypotension, bradycardia, and nonfatal cardiac arrest.

Citation: Devereaux PJ, Sessler DI, Leslie K, et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1504-1513.

Clinical question: Does peri-operative clonidine prevent myocardial infarction (MI)?

Background: A meta-analysis showed that peri-operative clonidine decreased death and MI compared to placebo in patients undergoing vascular surgery. It also showed that rates of death and MI were the same for patients taking clonidine vs. placebo undergoing nonvascular surgery without significant effects on hemodynamics.

Study design: Randomized controlled trial.

Setting: One hundred thirty-five centers across 23 countries.

Synopsis: The POISE-II [PeriOperative Ischemic Evaluation-II] study randomized 10,010 patients in a 1:1:1:1 fashion to analyze peri-operative clonidine and aspirin against placebo. This paper specifically examined the effects of peri-operative clonidine vs. placebo. The average age of the population was 69 years old. The most common comorbidities were diabetes (38%) and coronary artery disease (23%).

The outcomes showed that clonidine vs. placebo yielded insignificant results with respect to the primary endpoints (death, MI, or stroke: 7.6% vs. 7.0%; P=0.30); however, there were significantly higher rates of clinically significant hypotension (47.6% vs. 37.1%; P<0.001), bradycardia (12.0% vs. 8.1%; P<0.001), and nonfatal cardiac arrest (0.3% vs. 0.1%; P=0.02) in the clonidine group.

These results differ from previous, smaller studies, which suggested that there were no significant hemodynamic changes when patients received peri-operative clonidine.

Bottom line: Peri-operative clonidine does not affect the rate of MI but increases clinically significant hypotension, bradycardia, and nonfatal cardiac arrest.

Citation: Devereaux PJ, Sessler DI, Leslie K, et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1504-1513.

Clinical question: Does peri-operative clonidine prevent myocardial infarction (MI)?

Background: A meta-analysis showed that peri-operative clonidine decreased death and MI compared to placebo in patients undergoing vascular surgery. It also showed that rates of death and MI were the same for patients taking clonidine vs. placebo undergoing nonvascular surgery without significant effects on hemodynamics.

Study design: Randomized controlled trial.

Setting: One hundred thirty-five centers across 23 countries.

Synopsis: The POISE-II [PeriOperative Ischemic Evaluation-II] study randomized 10,010 patients in a 1:1:1:1 fashion to analyze peri-operative clonidine and aspirin against placebo. This paper specifically examined the effects of peri-operative clonidine vs. placebo. The average age of the population was 69 years old. The most common comorbidities were diabetes (38%) and coronary artery disease (23%).

The outcomes showed that clonidine vs. placebo yielded insignificant results with respect to the primary endpoints (death, MI, or stroke: 7.6% vs. 7.0%; P=0.30); however, there were significantly higher rates of clinically significant hypotension (47.6% vs. 37.1%; P<0.001), bradycardia (12.0% vs. 8.1%; P<0.001), and nonfatal cardiac arrest (0.3% vs. 0.1%; P=0.02) in the clonidine group.

These results differ from previous, smaller studies, which suggested that there were no significant hemodynamic changes when patients received peri-operative clonidine.

Bottom line: Peri-operative clonidine does not affect the rate of MI but increases clinically significant hypotension, bradycardia, and nonfatal cardiac arrest.

Citation: Devereaux PJ, Sessler DI, Leslie K, et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1504-1513.

Clinical question: Can a delirium severity score that coincides with clinical outcomes be developed?

Background: Quantification of the severity of delirium is important. Building on the Confusion Assessment Method (CAM) scoring system, the CAM-S was developed to help evaluate the severity of delirium.

Study design: Validation analysis in two independent cohorts.

Setting: Three academic medical centers.

Synopsis: Two cohorts of patients were included. The sample from the SAGES [Successful Aging after Elective Surgery] study included 300 patients aged 70 years or older undergoing major surgery. The sample from the Project Recovery study included 919 medical patients aged 70 years or older. There was a predominance of women in both studies. Patients were excluded if they had delirium or dementia present at baseline, recent hospitalization, a terminal diagnosis, vision and auditory impairment, or inability to speak English. A short, four-item form and 10-item longer form were developed, and scores on forms were correlated with outcomes both in the hospital and after discharge.

A higher severity score in both short and long forms was associated with a higher length of stay, as well as relative risk of death and nursing home residence at 90 days.

Limitations to the study were that all patients in the study were 70 years and older and that the Project Recovery sample used an older data set from 1995-1998.

Bottom line: The CAM-S represents a new delirium severity measurement system; it is associated with several clinical outcomes.

Citation: Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.

Clinical question: Can a delirium severity score that coincides with clinical outcomes be developed?

Background: Quantification of the severity of delirium is important. Building on the Confusion Assessment Method (CAM) scoring system, the CAM-S was developed to help evaluate the severity of delirium.

Study design: Validation analysis in two independent cohorts.

Setting: Three academic medical centers.

Synopsis: Two cohorts of patients were included. The sample from the SAGES [Successful Aging after Elective Surgery] study included 300 patients aged 70 years or older undergoing major surgery. The sample from the Project Recovery study included 919 medical patients aged 70 years or older. There was a predominance of women in both studies. Patients were excluded if they had delirium or dementia present at baseline, recent hospitalization, a terminal diagnosis, vision and auditory impairment, or inability to speak English. A short, four-item form and 10-item longer form were developed, and scores on forms were correlated with outcomes both in the hospital and after discharge.

A higher severity score in both short and long forms was associated with a higher length of stay, as well as relative risk of death and nursing home residence at 90 days.

Limitations to the study were that all patients in the study were 70 years and older and that the Project Recovery sample used an older data set from 1995-1998.

Bottom line: The CAM-S represents a new delirium severity measurement system; it is associated with several clinical outcomes.

Citation: Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.

Clinical question: Can a delirium severity score that coincides with clinical outcomes be developed?

Background: Quantification of the severity of delirium is important. Building on the Confusion Assessment Method (CAM) scoring system, the CAM-S was developed to help evaluate the severity of delirium.

Study design: Validation analysis in two independent cohorts.

Setting: Three academic medical centers.

Synopsis: Two cohorts of patients were included. The sample from the SAGES [Successful Aging after Elective Surgery] study included 300 patients aged 70 years or older undergoing major surgery. The sample from the Project Recovery study included 919 medical patients aged 70 years or older. There was a predominance of women in both studies. Patients were excluded if they had delirium or dementia present at baseline, recent hospitalization, a terminal diagnosis, vision and auditory impairment, or inability to speak English. A short, four-item form and 10-item longer form were developed, and scores on forms were correlated with outcomes both in the hospital and after discharge.

A higher severity score in both short and long forms was associated with a higher length of stay, as well as relative risk of death and nursing home residence at 90 days.

Limitations to the study were that all patients in the study were 70 years and older and that the Project Recovery sample used an older data set from 1995-1998.

Bottom line: The CAM-S represents a new delirium severity measurement system; it is associated with several clinical outcomes.

Citation: Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.

Clinical question: What are the risk factors identified at the onset of illness that are associated with recurrent C. diff infection?

Background: After initial infection, 10%-25% of patients experience recurrent C. diff infection (CDI). The identification of patients at high risk of recurrence would be beneficial for therapeutic decision making.

Study design: Retrospective cohort study.

Setting: Large, urban, academic medical center.

Synopsis: Authors included 4,196 patients with an initial infection, defined by a positive C. diff toxin assay and unformed stools. A repeat positive toxin within 42 days of completing treatment for the initial infection represented recurrent CDI. Multiple characteristics were examined to identify risks of recurrent infection, including demographics and those related to acute and chronic disease. A logistic regression model was used to identify risk factors for recurrence.

Four hundred twenty-five patients (10.1%) had recurrent infection. Age, fluoroquinolone and high-risk antibiotic use, community-acquired healthcare-associated infection, multiple hospitalizations, and gastric acid suppression were found to predict recurrent infection through multivariate analysis.

Limitations of the study included potential confounding, use of observational data, and generalizability, given the urban academic medical center setting. This prediction model differs from previously developed models in that it identifies factors present at the onset of infection.

Bottom line: Multiple factors identified at the onset of illness can predict CDI recurrence.

Citation: Zilberberg MD, Reske K, Olsen M, Yan Y, Dubberke ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med. 2014;9(7):418-423.

Clinical question: What are the risk factors identified at the onset of illness that are associated with recurrent C. diff infection?

Background: After initial infection, 10%-25% of patients experience recurrent C. diff infection (CDI). The identification of patients at high risk of recurrence would be beneficial for therapeutic decision making.

Study design: Retrospective cohort study.

Setting: Large, urban, academic medical center.

Synopsis: Authors included 4,196 patients with an initial infection, defined by a positive C. diff toxin assay and unformed stools. A repeat positive toxin within 42 days of completing treatment for the initial infection represented recurrent CDI. Multiple characteristics were examined to identify risks of recurrent infection, including demographics and those related to acute and chronic disease. A logistic regression model was used to identify risk factors for recurrence.

Four hundred twenty-five patients (10.1%) had recurrent infection. Age, fluoroquinolone and high-risk antibiotic use, community-acquired healthcare-associated infection, multiple hospitalizations, and gastric acid suppression were found to predict recurrent infection through multivariate analysis.

Limitations of the study included potential confounding, use of observational data, and generalizability, given the urban academic medical center setting. This prediction model differs from previously developed models in that it identifies factors present at the onset of infection.

Bottom line: Multiple factors identified at the onset of illness can predict CDI recurrence.

Citation: Zilberberg MD, Reske K, Olsen M, Yan Y, Dubberke ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med. 2014;9(7):418-423.

Clinical question: What are the risk factors identified at the onset of illness that are associated with recurrent C. diff infection?

Background: After initial infection, 10%-25% of patients experience recurrent C. diff infection (CDI). The identification of patients at high risk of recurrence would be beneficial for therapeutic decision making.

Study design: Retrospective cohort study.

Setting: Large, urban, academic medical center.

Synopsis: Authors included 4,196 patients with an initial infection, defined by a positive C. diff toxin assay and unformed stools. A repeat positive toxin within 42 days of completing treatment for the initial infection represented recurrent CDI. Multiple characteristics were examined to identify risks of recurrent infection, including demographics and those related to acute and chronic disease. A logistic regression model was used to identify risk factors for recurrence.

Four hundred twenty-five patients (10.1%) had recurrent infection. Age, fluoroquinolone and high-risk antibiotic use, community-acquired healthcare-associated infection, multiple hospitalizations, and gastric acid suppression were found to predict recurrent infection through multivariate analysis.

Limitations of the study included potential confounding, use of observational data, and generalizability, given the urban academic medical center setting. This prediction model differs from previously developed models in that it identifies factors present at the onset of infection.

Bottom line: Multiple factors identified at the onset of illness can predict CDI recurrence.

Citation: Zilberberg MD, Reske K, Olsen M, Yan Y, Dubberke ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med. 2014;9(7):418-423.

Chad Whelan, MD, FHM, began his new role as chief medical officer at Loyola University Health System in Chicago on June 1. Dr. Whelan previously worked as director of the hospital medicine division at Loyola before serving as associate chief medical officer at the University of Chicago Medical Center.

Matthew Dunn, MD, is the 2014 Nathan Avery Physician of the Year at Flagstaff (Ariz.) Medical Center (FMC). Dr. Dunn has worked at FMC as an adult hospitalist since 2011 and a pediatric hospitalist since July 2012 when FMC launched its pediatric hospitalist program. Dr. Dunn is known for his emphasis on patient- and family-centered care as well as interdisciplinary teamwork.

Barbara Michael, MD, and Jim K. Hudson III, MD, were recently honored as two of the Knoxville, Tenn.-based TeamHealth’s 2014 Medical Directors of the Year. Dr. Michael, the hospital medicine honoree, is hospitalist medical director at St. Francis Hospital in Charleston, W.Va. Dr. Hudson, the specialty hospitalist honoree, is medical director of orthopedic surgery at Baptist Memorial Hospital in Memphis, Tenn.

Murthy Madduri, MD, has been named the new hospitalist medical director at CaroMont Regional Medical Center in Gastonia, N.C. Dr. Madduri has been a practicing hospitalist since 1996 and a hospitalist medical director at various institutions since 2000.

Brian Pate, MD, is the new chair of the pediatrics department at the University of Kansas School of Medicine in Wichita. Prior to his current position, Dr. Pate served as pediatric hospitalist division director and vice president of inpatient services at Children’s Mercy Hospital in Kansas City, Mo.

Chad Whelan, MD, FHM, began his new role as chief medical officer at Loyola University Health System in Chicago on June 1. Dr. Whelan previously worked as director of the hospital medicine division at Loyola before serving as associate chief medical officer at the University of Chicago Medical Center.

Matthew Dunn, MD, is the 2014 Nathan Avery Physician of the Year at Flagstaff (Ariz.) Medical Center (FMC). Dr. Dunn has worked at FMC as an adult hospitalist since 2011 and a pediatric hospitalist since July 2012 when FMC launched its pediatric hospitalist program. Dr. Dunn is known for his emphasis on patient- and family-centered care as well as interdisciplinary teamwork.

Barbara Michael, MD, and Jim K. Hudson III, MD, were recently honored as two of the Knoxville, Tenn.-based TeamHealth’s 2014 Medical Directors of the Year. Dr. Michael, the hospital medicine honoree, is hospitalist medical director at St. Francis Hospital in Charleston, W.Va. Dr. Hudson, the specialty hospitalist honoree, is medical director of orthopedic surgery at Baptist Memorial Hospital in Memphis, Tenn.

Murthy Madduri, MD, has been named the new hospitalist medical director at CaroMont Regional Medical Center in Gastonia, N.C. Dr. Madduri has been a practicing hospitalist since 1996 and a hospitalist medical director at various institutions since 2000.

Brian Pate, MD, is the new chair of the pediatrics department at the University of Kansas School of Medicine in Wichita. Prior to his current position, Dr. Pate served as pediatric hospitalist division director and vice president of inpatient services at Children’s Mercy Hospital in Kansas City, Mo.

Chad Whelan, MD, FHM, began his new role as chief medical officer at Loyola University Health System in Chicago on June 1. Dr. Whelan previously worked as director of the hospital medicine division at Loyola before serving as associate chief medical officer at the University of Chicago Medical Center.

Matthew Dunn, MD, is the 2014 Nathan Avery Physician of the Year at Flagstaff (Ariz.) Medical Center (FMC). Dr. Dunn has worked at FMC as an adult hospitalist since 2011 and a pediatric hospitalist since July 2012 when FMC launched its pediatric hospitalist program. Dr. Dunn is known for his emphasis on patient- and family-centered care as well as interdisciplinary teamwork.

Barbara Michael, MD, and Jim K. Hudson III, MD, were recently honored as two of the Knoxville, Tenn.-based TeamHealth’s 2014 Medical Directors of the Year. Dr. Michael, the hospital medicine honoree, is hospitalist medical director at St. Francis Hospital in Charleston, W.Va. Dr. Hudson, the specialty hospitalist honoree, is medical director of orthopedic surgery at Baptist Memorial Hospital in Memphis, Tenn.

Murthy Madduri, MD, has been named the new hospitalist medical director at CaroMont Regional Medical Center in Gastonia, N.C. Dr. Madduri has been a practicing hospitalist since 1996 and a hospitalist medical director at various institutions since 2000.

Brian Pate, MD, is the new chair of the pediatrics department at the University of Kansas School of Medicine in Wichita. Prior to his current position, Dr. Pate served as pediatric hospitalist division director and vice president of inpatient services at Children’s Mercy Hospital in Kansas City, Mo.

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to [email protected].

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to [email protected].

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to [email protected].

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

Recruiting and retaining hospitalists are major challenges for hospital medicine groups across the country, and the State of Hospital Medicine report can be the roadmap for helping them keep the hospitalists they need.

The State of Hospital Medicine, available in September from SHM, provides a comprehensive data set on compensation and productivity for hospitalists across the country—and across sub-specialties in HM. Using data from the State of Hospital Medicine report, hospitalists everywhere compare their own compensation strategies against those in their region and throughout the U.S.

The latest issue, published by SHM every other year, will be available later this month but can be pre-ordered today. For more information, or to pre-order, visit www.hospitalmedicine.org/sohm.

Recruiting and retaining hospitalists are major challenges for hospital medicine groups across the country, and the State of Hospital Medicine report can be the roadmap for helping them keep the hospitalists they need.

The State of Hospital Medicine, available in September from SHM, provides a comprehensive data set on compensation and productivity for hospitalists across the country—and across sub-specialties in HM. Using data from the State of Hospital Medicine report, hospitalists everywhere compare their own compensation strategies against those in their region and throughout the U.S.

The latest issue, published by SHM every other year, will be available later this month but can be pre-ordered today. For more information, or to pre-order, visit www.hospitalmedicine.org/sohm.

Recruiting and retaining hospitalists are major challenges for hospital medicine groups across the country, and the State of Hospital Medicine report can be the roadmap for helping them keep the hospitalists they need.

The State of Hospital Medicine, available in September from SHM, provides a comprehensive data set on compensation and productivity for hospitalists across the country—and across sub-specialties in HM. Using data from the State of Hospital Medicine report, hospitalists everywhere compare their own compensation strategies against those in their region and throughout the U.S.

The latest issue, published by SHM every other year, will be available later this month but can be pre-ordered today. For more information, or to pre-order, visit www.hospitalmedicine.org/sohm.

Now is the time to clear space on your calendar for Hospital Medicine 2015: March 29 through April 1, 2015. Hospitalists often tell SHM that the main reason they can’t make it to our annual meeting is schedule conflicts, so reserving time in your busy schedules today ensures that you can meet with fellow hospitalists at HM15 in just a few months.

Since HM15 will be just a few miles from the nation’s capital, SHM is organizing another specialty-wide Hospitalists on the Hill, where hospitalists from across the country meet with lawmakers to discuss the major challenges facing care for hospitalized patients. Now more than ever, hospitalists are a force for change in Washington, testifying before Congress and meeting with lawmakers in record numbers.

Hospital Medicine 2015

March 29-April 1

National Harbor, Maryland, just outside of Washington, D.C.

www.hospitalmedicine2015.org

Now is the time to clear space on your calendar for Hospital Medicine 2015: March 29 through April 1, 2015. Hospitalists often tell SHM that the main reason they can’t make it to our annual meeting is schedule conflicts, so reserving time in your busy schedules today ensures that you can meet with fellow hospitalists at HM15 in just a few months.

Since HM15 will be just a few miles from the nation’s capital, SHM is organizing another specialty-wide Hospitalists on the Hill, where hospitalists from across the country meet with lawmakers to discuss the major challenges facing care for hospitalized patients. Now more than ever, hospitalists are a force for change in Washington, testifying before Congress and meeting with lawmakers in record numbers.

Hospital Medicine 2015

March 29-April 1

National Harbor, Maryland, just outside of Washington, D.C.

www.hospitalmedicine2015.org

Now is the time to clear space on your calendar for Hospital Medicine 2015: March 29 through April 1, 2015. Hospitalists often tell SHM that the main reason they can’t make it to our annual meeting is schedule conflicts, so reserving time in your busy schedules today ensures that you can meet with fellow hospitalists at HM15 in just a few months.

Since HM15 will be just a few miles from the nation’s capital, SHM is organizing another specialty-wide Hospitalists on the Hill, where hospitalists from across the country meet with lawmakers to discuss the major challenges facing care for hospitalized patients. Now more than ever, hospitalists are a force for change in Washington, testifying before Congress and meeting with lawmakers in record numbers.

Hospital Medicine 2015

March 29-April 1

National Harbor, Maryland, just outside of Washington, D.C.

www.hospitalmedicine2015.org