In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

LAS VEGAS—Hospitalist Amy Knight, MD, isn’t a chief medical informatics officer (CMIO). She calls herself a “CMIO lite,” a nod to her title as medical advisor to the department of information services at her home hospital, Johns Hopkins Bayview Medical Center in Baltimore.

But, CMIO or not, she was among the first cohort of 450 medical professionals to be board-certified in medical informatics last fall after an exam for the specialty was created by the American Board of Medical Specialties.

Now Dr. Knight, who serves as a technology advocate for SHM, thinks more hospitalists should follow her lead.

“I had a little chip on my shoulder because I didn’t do a fellowship in informatics,” said Dr. Knight, who nonetheless worked on Bayview’s implementation of computerized provider order entry and electronic provider documentation systems. “I wanted some sort of recognition for everything I’d been doing. We’re already doing it, so let’s get some recognition for it, some credentials—and also, some standards for what the minimum needed to do a good job are.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, agrees. He wants as many hospitalists as possible to “establish ourselves for the informatics role we have taken.”

Whether it was lamenting clunky electronic health records (EHR) systems, discussing Dr. Rogers’ push for so-called “techno-docs” to consider the new board certification, or lobbying for people to interact more with SHM’s Hospital Medicine Exchange (HMX), hospitalists at HM14 took the opportunity to focus on the growing pains of health information technology (IT).

For Mohammed Morad, MD, a hospitalist at Indiana University Health Ball Memorial Hospital in Muncie, the paramount frustration is the trouble providers have with EHR systems that are built for physicians but don’t seem to consider the end user.

“These EHRs are designed to make your billing easier,” Dr. Morad said. “[They’re] not designed for patient safety or quality measures. Now they’re trying to implement some of these tools, but the usability...is very challenging, especially for physicians who are not tech-savvy enough. Even [for] newly graduated doctors with iPhones, it’s still a challenge. It’s not user-friendly.”

Dr. Morad’s biggest frustration with the technology is how time-consuming it is. Although electronic input is clearly more advanced, more communal, and more privacy-focused than hand-written notes, current systems that require physicians to spend hours upon hours building order sets or typing out notes waste too much valuable time, he said.

“You spend more time with these EHRs than you spend with your patients, because you have to put the orders in, you have to write the note, you have to look at previous reports,” Dr. Morad added. “In a way, it helps in gathering the information that you need in one place so before I even see the patient I know what the echo[cardiogram] showed, what the chest X-ray showed, what the previous consultant had seen....but how easy is it to get all this? It takes more time than it should.”

Despite expressing frustration with current systems, most hospitalists are cautiously optimistic about advances in technology. Dr. Morad is hopeful that future iterations of the systems will be “more intuitive” and consider physicians’ needs instead of creating templates that individual institutions have to spend time and money customizing.

“Compared to any other software, they’re behind,” he said. “They’re not going to get better unless some people step up and try to make them better, especially from a physician perspective.”

Gaurav Chaturvedi, MD, head of the hospitalist team at Northwestern Lake Forest (Ill.) Hospital and chair of SHM’s IT Quality Subcommittee, said part of the problem is that vendors have a captive audience. Hospitals are motivated to take advantage of health IT incentive payments, which were funded under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Because healthcare reform is pushing the industry to digitize medical records, IT firms have built-in customers. That, Dr. Chaturvedi said, has stifled competition and hampered innovations tailored to doctors’ needs.

Hospitalists must work together to discuss end-user issues and prompt improvement, he added. To that end, SHM technology committees are working on white papers that will recommend best practices related to health information technology. While the papers are still in the planning and polishing phase, the idea is to view the overall landscape to give HM group leaders a framework of what they should be focused on.

“We want to keep vendor-neutral,” Dr. Chaturvedi said. “We all have the same types of issues to work with. We should work it out together.”

Dr. Rogers noted that SHM has met proactively with vendors to provide input on potential improvements, but that the process is ongoing and will likely take years.

“The best is still pretty bad out there,” he added.

Meanwhile, he urged hospitalists to share concerns, complaints, and success stories via HMX, an online portal hospitalists can use to communicate their views on a variety of topics, post responses, and share files. The online community—launched three years ago but rebranded under its current name in 2012—can be a repository for advice, ideas, or commiseration but is useful only if it is adopted. If more hospitalists log into the system and begin to use it, participation will breed greater value and vice versa, he added.

“We’re still in the build-up phase,” Dr. Rogers said. “We want to get people in all discussion forums to a tipping point.”

LAS VEGAS—Hospitalist Amy Knight, MD, isn’t a chief medical informatics officer (CMIO). She calls herself a “CMIO lite,” a nod to her title as medical advisor to the department of information services at her home hospital, Johns Hopkins Bayview Medical Center in Baltimore.

But, CMIO or not, she was among the first cohort of 450 medical professionals to be board-certified in medical informatics last fall after an exam for the specialty was created by the American Board of Medical Specialties.

Now Dr. Knight, who serves as a technology advocate for SHM, thinks more hospitalists should follow her lead.

“I had a little chip on my shoulder because I didn’t do a fellowship in informatics,” said Dr. Knight, who nonetheless worked on Bayview’s implementation of computerized provider order entry and electronic provider documentation systems. “I wanted some sort of recognition for everything I’d been doing. We’re already doing it, so let’s get some recognition for it, some credentials—and also, some standards for what the minimum needed to do a good job are.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, agrees. He wants as many hospitalists as possible to “establish ourselves for the informatics role we have taken.”

Whether it was lamenting clunky electronic health records (EHR) systems, discussing Dr. Rogers’ push for so-called “techno-docs” to consider the new board certification, or lobbying for people to interact more with SHM’s Hospital Medicine Exchange (HMX), hospitalists at HM14 took the opportunity to focus on the growing pains of health information technology (IT).

For Mohammed Morad, MD, a hospitalist at Indiana University Health Ball Memorial Hospital in Muncie, the paramount frustration is the trouble providers have with EHR systems that are built for physicians but don’t seem to consider the end user.

“These EHRs are designed to make your billing easier,” Dr. Morad said. “[They’re] not designed for patient safety or quality measures. Now they’re trying to implement some of these tools, but the usability...is very challenging, especially for physicians who are not tech-savvy enough. Even [for] newly graduated doctors with iPhones, it’s still a challenge. It’s not user-friendly.”

Dr. Morad’s biggest frustration with the technology is how time-consuming it is. Although electronic input is clearly more advanced, more communal, and more privacy-focused than hand-written notes, current systems that require physicians to spend hours upon hours building order sets or typing out notes waste too much valuable time, he said.

“You spend more time with these EHRs than you spend with your patients, because you have to put the orders in, you have to write the note, you have to look at previous reports,” Dr. Morad added. “In a way, it helps in gathering the information that you need in one place so before I even see the patient I know what the echo[cardiogram] showed, what the chest X-ray showed, what the previous consultant had seen....but how easy is it to get all this? It takes more time than it should.”

Despite expressing frustration with current systems, most hospitalists are cautiously optimistic about advances in technology. Dr. Morad is hopeful that future iterations of the systems will be “more intuitive” and consider physicians’ needs instead of creating templates that individual institutions have to spend time and money customizing.

“Compared to any other software, they’re behind,” he said. “They’re not going to get better unless some people step up and try to make them better, especially from a physician perspective.”

Gaurav Chaturvedi, MD, head of the hospitalist team at Northwestern Lake Forest (Ill.) Hospital and chair of SHM’s IT Quality Subcommittee, said part of the problem is that vendors have a captive audience. Hospitals are motivated to take advantage of health IT incentive payments, which were funded under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Because healthcare reform is pushing the industry to digitize medical records, IT firms have built-in customers. That, Dr. Chaturvedi said, has stifled competition and hampered innovations tailored to doctors’ needs.

Hospitalists must work together to discuss end-user issues and prompt improvement, he added. To that end, SHM technology committees are working on white papers that will recommend best practices related to health information technology. While the papers are still in the planning and polishing phase, the idea is to view the overall landscape to give HM group leaders a framework of what they should be focused on.

“We want to keep vendor-neutral,” Dr. Chaturvedi said. “We all have the same types of issues to work with. We should work it out together.”

Dr. Rogers noted that SHM has met proactively with vendors to provide input on potential improvements, but that the process is ongoing and will likely take years.

“The best is still pretty bad out there,” he added.

Meanwhile, he urged hospitalists to share concerns, complaints, and success stories via HMX, an online portal hospitalists can use to communicate their views on a variety of topics, post responses, and share files. The online community—launched three years ago but rebranded under its current name in 2012—can be a repository for advice, ideas, or commiseration but is useful only if it is adopted. If more hospitalists log into the system and begin to use it, participation will breed greater value and vice versa, he added.

“We’re still in the build-up phase,” Dr. Rogers said. “We want to get people in all discussion forums to a tipping point.”

LAS VEGAS—Hospitalist Amy Knight, MD, isn’t a chief medical informatics officer (CMIO). She calls herself a “CMIO lite,” a nod to her title as medical advisor to the department of information services at her home hospital, Johns Hopkins Bayview Medical Center in Baltimore.

But, CMIO or not, she was among the first cohort of 450 medical professionals to be board-certified in medical informatics last fall after an exam for the specialty was created by the American Board of Medical Specialties.

Now Dr. Knight, who serves as a technology advocate for SHM, thinks more hospitalists should follow her lead.

“I had a little chip on my shoulder because I didn’t do a fellowship in informatics,” said Dr. Knight, who nonetheless worked on Bayview’s implementation of computerized provider order entry and electronic provider documentation systems. “I wanted some sort of recognition for everything I’d been doing. We’re already doing it, so let’s get some recognition for it, some credentials—and also, some standards for what the minimum needed to do a good job are.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, agrees. He wants as many hospitalists as possible to “establish ourselves for the informatics role we have taken.”

Whether it was lamenting clunky electronic health records (EHR) systems, discussing Dr. Rogers’ push for so-called “techno-docs” to consider the new board certification, or lobbying for people to interact more with SHM’s Hospital Medicine Exchange (HMX), hospitalists at HM14 took the opportunity to focus on the growing pains of health information technology (IT).

For Mohammed Morad, MD, a hospitalist at Indiana University Health Ball Memorial Hospital in Muncie, the paramount frustration is the trouble providers have with EHR systems that are built for physicians but don’t seem to consider the end user.

“These EHRs are designed to make your billing easier,” Dr. Morad said. “[They’re] not designed for patient safety or quality measures. Now they’re trying to implement some of these tools, but the usability...is very challenging, especially for physicians who are not tech-savvy enough. Even [for] newly graduated doctors with iPhones, it’s still a challenge. It’s not user-friendly.”

Dr. Morad’s biggest frustration with the technology is how time-consuming it is. Although electronic input is clearly more advanced, more communal, and more privacy-focused than hand-written notes, current systems that require physicians to spend hours upon hours building order sets or typing out notes waste too much valuable time, he said.

“You spend more time with these EHRs than you spend with your patients, because you have to put the orders in, you have to write the note, you have to look at previous reports,” Dr. Morad added. “In a way, it helps in gathering the information that you need in one place so before I even see the patient I know what the echo[cardiogram] showed, what the chest X-ray showed, what the previous consultant had seen....but how easy is it to get all this? It takes more time than it should.”

Despite expressing frustration with current systems, most hospitalists are cautiously optimistic about advances in technology. Dr. Morad is hopeful that future iterations of the systems will be “more intuitive” and consider physicians’ needs instead of creating templates that individual institutions have to spend time and money customizing.

“Compared to any other software, they’re behind,” he said. “They’re not going to get better unless some people step up and try to make them better, especially from a physician perspective.”

Gaurav Chaturvedi, MD, head of the hospitalist team at Northwestern Lake Forest (Ill.) Hospital and chair of SHM’s IT Quality Subcommittee, said part of the problem is that vendors have a captive audience. Hospitals are motivated to take advantage of health IT incentive payments, which were funded under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Because healthcare reform is pushing the industry to digitize medical records, IT firms have built-in customers. That, Dr. Chaturvedi said, has stifled competition and hampered innovations tailored to doctors’ needs.

Hospitalists must work together to discuss end-user issues and prompt improvement, he added. To that end, SHM technology committees are working on white papers that will recommend best practices related to health information technology. While the papers are still in the planning and polishing phase, the idea is to view the overall landscape to give HM group leaders a framework of what they should be focused on.

“We want to keep vendor-neutral,” Dr. Chaturvedi said. “We all have the same types of issues to work with. We should work it out together.”

Dr. Rogers noted that SHM has met proactively with vendors to provide input on potential improvements, but that the process is ongoing and will likely take years.

“The best is still pretty bad out there,” he added.

Meanwhile, he urged hospitalists to share concerns, complaints, and success stories via HMX, an online portal hospitalists can use to communicate their views on a variety of topics, post responses, and share files. The online community—launched three years ago but rebranded under its current name in 2012—can be a repository for advice, ideas, or commiseration but is useful only if it is adopted. If more hospitalists log into the system and begin to use it, participation will breed greater value and vice versa, he added.

“We’re still in the build-up phase,” Dr. Rogers said. “We want to get people in all discussion forums to a tipping point.”

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LAS VEGAS—To an untrained eye, the poster looked a lot like the hundreds of others that lined the exhibit hall here at Mandalay Bay Resort and Casino. But this one belonged to hospitalist Cathy Jones, MD, an associate chief medical officer (CMO) for medical services at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

The poster, “The Daily Safety Check-In: A Strategy For Reducing Serious Harm to Patients,” highlighted the hospital’s use of a daily safety check-in (DSCI) that gathers hospitalists, nurses, infection-control staff, and at least one representative from its CMO office to discuss the patient census. The meeting—held without fail each morning at 9:05, 365 days a year, including holidays—takes at least 30 minutes, time that might seem like too much to some observers who couldn’t imagine squeezing another half-hour meeting into their schedule.

But to Dr. Jones, the DSCI is worth every second, and she wanted—practically needed—to share it. “We think this is saving lives in our organization,” she says. “Maybe somebody else will see this and say, ‘We could do that,’ and maybe it would make a difference there, too.”

Therein lies the point of the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition: hospitalists sharing profound thoughts, creative pilot programs, and unique cases with their brethren from around the country.

“Sometimes you’re so close to a problem, you just can’t figure it out,” says Dr. Jones, whose poster came in second place in the Innovations category. “You keep trying the same old things and they don’t work. Then you come here and you say, ‘Oh, they’ve done some training (on) that problem at our hospital.’ And often you have the opportunity to talk to the person and say, “Tell me, what’s your curriculum? Who teaches it?’... This sharing of ideas is what’s so nice about the poster sessions.”

Some ideas, such as Dr. Jones’ DSCI, might seem too big to tackle. Others, like a paper presented by third-year internal medicine resident Lekshmi Santhosh, MD, from the University of California at San Francisco (UCSF), can be as simple as an innovative update on how doctors send and receive electronic pages.

Dr. Santhosh’s poster, “CareWeb Messenger: A Facebook/Twitter/Paging Hybrid for Collaborative Care,” showcases a web-based paging tool that combines features of Facebook and Twitter and allows users to send, receive, view, search, and store messages on a patient’s “wall,” while routing each message to a provider’s pager and wireless phone. The idea is to ease the perceived burden of answering pages while also improving communication skills.

The concept resonates well; a panel of judges awarded it the best poster by a trainee in the Innovations competition. And, while Dr. Santhosh was humbly honored, she says talking to other physicians is the reason she was excited to present.

“Somebody from (the University of Pennsylvania) came up to me—totally opposite coast—and he showed me what they’re using, which is basically an SMS text-based system,” Dr. Santhosh adds. “I was sharing ideas with him. I would never have been able to meet him or even hear about what they’re doing at Penn if not for forums like this.”

The ability to crowd-source ideas at the poster competition appealed to Susan Hunt, MD, a hospitalist at Seattle Children’s Hospital and the University of Washington Medical Center and one of SHM’s judges for the Innovations portion of the poster competition. Dr. Hunt says it’s difficult choosing winners because there are so many good presentations, but, more importantly, hospitalists should use the competition as a chance to see the best of the best and then pick out concepts that might work at their hospital.

“How translatable is it?” Dr. Hunt says, listing off judging criteria. “How applicable is it to the general hospitalist population? Community hospitalists? Academic hospitalists? How will this help them provide better care for their patients, better job satisfaction, better training? Some of the ones that didn’t win are still great ideas.”

Take the project presented by a trio of hospitalists from Rush University Medical Center in Chicago. The poster, “Guidelines, Education, and Email Alerts Can Decrease Transfusions in General Medicine Patients,” explained a project to “increase adherence to a restrictive transfusion guideline for patients admitted to general medicine floors.” The intervention suggested a transfusion threshold of Hgb<7 in upper GI bleed patients, except in cases of hemodynamic instability. In all other indications, the threshold was Hgb<8.

The research found that when samples from three months before the intervention were compared with samples collected three months post-intervention, the number of transfused units dropped to 273 from 481. In the pre-intervention sample, there were 95 units of blood delivered with a pre-transfusion Hgb>8; in the post-intervention group, only 18 units were delivered.

But Rush hospitalist Jisu Kim, MD, FHM, isn’t stopping with a poster. “This is one of the endpoints,” Dr. Kim says. “We want to see how much further we can go. Can this be a publishable paper? What’s the next step for our other projects? We’re getting motivated by it.”

Dr. Kim believes that in addition to sharing information, getting the next generation of physicians involved in the poster competition inspires young physicians to further engage in their specialty. To that end, residents Manya Gupta, MD, and Lesley Schmaltz, MD, say they are grateful to be part of the presentation.

“It’s very rewarding because it makes you want to keep moving forward and keep making those improvements,” says Dr. Schmaltz. “That’s why I think we all do our posters and presentations: to help the greater good of all physicians throughout the country.”

“It’s been a really great learning experience to get your feet wet,” Dr. Gupta says. “You just have to try it out once and find out what it’s like; otherwise it seems so daunting. Then you realize, ‘We can do this.’”

LAS VEGAS—To an untrained eye, the poster looked a lot like the hundreds of others that lined the exhibit hall here at Mandalay Bay Resort and Casino. But this one belonged to hospitalist Cathy Jones, MD, an associate chief medical officer (CMO) for medical services at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

The poster, “The Daily Safety Check-In: A Strategy For Reducing Serious Harm to Patients,” highlighted the hospital’s use of a daily safety check-in (DSCI) that gathers hospitalists, nurses, infection-control staff, and at least one representative from its CMO office to discuss the patient census. The meeting—held without fail each morning at 9:05, 365 days a year, including holidays—takes at least 30 minutes, time that might seem like too much to some observers who couldn’t imagine squeezing another half-hour meeting into their schedule.

But to Dr. Jones, the DSCI is worth every second, and she wanted—practically needed—to share it. “We think this is saving lives in our organization,” she says. “Maybe somebody else will see this and say, ‘We could do that,’ and maybe it would make a difference there, too.”

Therein lies the point of the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition: hospitalists sharing profound thoughts, creative pilot programs, and unique cases with their brethren from around the country.

“Sometimes you’re so close to a problem, you just can’t figure it out,” says Dr. Jones, whose poster came in second place in the Innovations category. “You keep trying the same old things and they don’t work. Then you come here and you say, ‘Oh, they’ve done some training (on) that problem at our hospital.’ And often you have the opportunity to talk to the person and say, “Tell me, what’s your curriculum? Who teaches it?’... This sharing of ideas is what’s so nice about the poster sessions.”

Some ideas, such as Dr. Jones’ DSCI, might seem too big to tackle. Others, like a paper presented by third-year internal medicine resident Lekshmi Santhosh, MD, from the University of California at San Francisco (UCSF), can be as simple as an innovative update on how doctors send and receive electronic pages.

Dr. Santhosh’s poster, “CareWeb Messenger: A Facebook/Twitter/Paging Hybrid for Collaborative Care,” showcases a web-based paging tool that combines features of Facebook and Twitter and allows users to send, receive, view, search, and store messages on a patient’s “wall,” while routing each message to a provider’s pager and wireless phone. The idea is to ease the perceived burden of answering pages while also improving communication skills.

The concept resonates well; a panel of judges awarded it the best poster by a trainee in the Innovations competition. And, while Dr. Santhosh was humbly honored, she says talking to other physicians is the reason she was excited to present.

“Somebody from (the University of Pennsylvania) came up to me—totally opposite coast—and he showed me what they’re using, which is basically an SMS text-based system,” Dr. Santhosh adds. “I was sharing ideas with him. I would never have been able to meet him or even hear about what they’re doing at Penn if not for forums like this.”

The ability to crowd-source ideas at the poster competition appealed to Susan Hunt, MD, a hospitalist at Seattle Children’s Hospital and the University of Washington Medical Center and one of SHM’s judges for the Innovations portion of the poster competition. Dr. Hunt says it’s difficult choosing winners because there are so many good presentations, but, more importantly, hospitalists should use the competition as a chance to see the best of the best and then pick out concepts that might work at their hospital.

“How translatable is it?” Dr. Hunt says, listing off judging criteria. “How applicable is it to the general hospitalist population? Community hospitalists? Academic hospitalists? How will this help them provide better care for their patients, better job satisfaction, better training? Some of the ones that didn’t win are still great ideas.”

Take the project presented by a trio of hospitalists from Rush University Medical Center in Chicago. The poster, “Guidelines, Education, and Email Alerts Can Decrease Transfusions in General Medicine Patients,” explained a project to “increase adherence to a restrictive transfusion guideline for patients admitted to general medicine floors.” The intervention suggested a transfusion threshold of Hgb<7 in upper GI bleed patients, except in cases of hemodynamic instability. In all other indications, the threshold was Hgb<8.

The research found that when samples from three months before the intervention were compared with samples collected three months post-intervention, the number of transfused units dropped to 273 from 481. In the pre-intervention sample, there were 95 units of blood delivered with a pre-transfusion Hgb>8; in the post-intervention group, only 18 units were delivered.

But Rush hospitalist Jisu Kim, MD, FHM, isn’t stopping with a poster. “This is one of the endpoints,” Dr. Kim says. “We want to see how much further we can go. Can this be a publishable paper? What’s the next step for our other projects? We’re getting motivated by it.”

Dr. Kim believes that in addition to sharing information, getting the next generation of physicians involved in the poster competition inspires young physicians to further engage in their specialty. To that end, residents Manya Gupta, MD, and Lesley Schmaltz, MD, say they are grateful to be part of the presentation.

“It’s very rewarding because it makes you want to keep moving forward and keep making those improvements,” says Dr. Schmaltz. “That’s why I think we all do our posters and presentations: to help the greater good of all physicians throughout the country.”

“It’s been a really great learning experience to get your feet wet,” Dr. Gupta says. “You just have to try it out once and find out what it’s like; otherwise it seems so daunting. Then you realize, ‘We can do this.’”

LAS VEGAS—To an untrained eye, the poster looked a lot like the hundreds of others that lined the exhibit hall here at Mandalay Bay Resort and Casino. But this one belonged to hospitalist Cathy Jones, MD, an associate chief medical officer (CMO) for medical services at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

The poster, “The Daily Safety Check-In: A Strategy For Reducing Serious Harm to Patients,” highlighted the hospital’s use of a daily safety check-in (DSCI) that gathers hospitalists, nurses, infection-control staff, and at least one representative from its CMO office to discuss the patient census. The meeting—held without fail each morning at 9:05, 365 days a year, including holidays—takes at least 30 minutes, time that might seem like too much to some observers who couldn’t imagine squeezing another half-hour meeting into their schedule.

But to Dr. Jones, the DSCI is worth every second, and she wanted—practically needed—to share it. “We think this is saving lives in our organization,” she says. “Maybe somebody else will see this and say, ‘We could do that,’ and maybe it would make a difference there, too.”

Therein lies the point of the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition: hospitalists sharing profound thoughts, creative pilot programs, and unique cases with their brethren from around the country.

“Sometimes you’re so close to a problem, you just can’t figure it out,” says Dr. Jones, whose poster came in second place in the Innovations category. “You keep trying the same old things and they don’t work. Then you come here and you say, ‘Oh, they’ve done some training (on) that problem at our hospital.’ And often you have the opportunity to talk to the person and say, “Tell me, what’s your curriculum? Who teaches it?’... This sharing of ideas is what’s so nice about the poster sessions.”

Some ideas, such as Dr. Jones’ DSCI, might seem too big to tackle. Others, like a paper presented by third-year internal medicine resident Lekshmi Santhosh, MD, from the University of California at San Francisco (UCSF), can be as simple as an innovative update on how doctors send and receive electronic pages.

Dr. Santhosh’s poster, “CareWeb Messenger: A Facebook/Twitter/Paging Hybrid for Collaborative Care,” showcases a web-based paging tool that combines features of Facebook and Twitter and allows users to send, receive, view, search, and store messages on a patient’s “wall,” while routing each message to a provider’s pager and wireless phone. The idea is to ease the perceived burden of answering pages while also improving communication skills.

The concept resonates well; a panel of judges awarded it the best poster by a trainee in the Innovations competition. And, while Dr. Santhosh was humbly honored, she says talking to other physicians is the reason she was excited to present.

“Somebody from (the University of Pennsylvania) came up to me—totally opposite coast—and he showed me what they’re using, which is basically an SMS text-based system,” Dr. Santhosh adds. “I was sharing ideas with him. I would never have been able to meet him or even hear about what they’re doing at Penn if not for forums like this.”

The ability to crowd-source ideas at the poster competition appealed to Susan Hunt, MD, a hospitalist at Seattle Children’s Hospital and the University of Washington Medical Center and one of SHM’s judges for the Innovations portion of the poster competition. Dr. Hunt says it’s difficult choosing winners because there are so many good presentations, but, more importantly, hospitalists should use the competition as a chance to see the best of the best and then pick out concepts that might work at their hospital.

“How translatable is it?” Dr. Hunt says, listing off judging criteria. “How applicable is it to the general hospitalist population? Community hospitalists? Academic hospitalists? How will this help them provide better care for their patients, better job satisfaction, better training? Some of the ones that didn’t win are still great ideas.”

Take the project presented by a trio of hospitalists from Rush University Medical Center in Chicago. The poster, “Guidelines, Education, and Email Alerts Can Decrease Transfusions in General Medicine Patients,” explained a project to “increase adherence to a restrictive transfusion guideline for patients admitted to general medicine floors.” The intervention suggested a transfusion threshold of Hgb<7 in upper GI bleed patients, except in cases of hemodynamic instability. In all other indications, the threshold was Hgb<8.

The research found that when samples from three months before the intervention were compared with samples collected three months post-intervention, the number of transfused units dropped to 273 from 481. In the pre-intervention sample, there were 95 units of blood delivered with a pre-transfusion Hgb>8; in the post-intervention group, only 18 units were delivered.

But Rush hospitalist Jisu Kim, MD, FHM, isn’t stopping with a poster. “This is one of the endpoints,” Dr. Kim says. “We want to see how much further we can go. Can this be a publishable paper? What’s the next step for our other projects? We’re getting motivated by it.”

Dr. Kim believes that in addition to sharing information, getting the next generation of physicians involved in the poster competition inspires young physicians to further engage in their specialty. To that end, residents Manya Gupta, MD, and Lesley Schmaltz, MD, say they are grateful to be part of the presentation.

“It’s very rewarding because it makes you want to keep moving forward and keep making those improvements,” says Dr. Schmaltz. “That’s why I think we all do our posters and presentations: to help the greater good of all physicians throughout the country.”

“It’s been a really great learning experience to get your feet wet,” Dr. Gupta says. “You just have to try it out once and find out what it’s like; otherwise it seems so daunting. Then you realize, ‘We can do this.’”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—As America’s favorite pastime began a new season, hospitalists from all parts of the country engaged in a variety of healthcare policy discussions at HM14. That’s why the baseball analogy that SHM advocacy guru Ron Greeno, MD, MHM, used to describe how far along the industry is in implementing the Affordable Care Act (ACA) was particularly fitting: “We’re in the first inning,” he said.

So, while hospitalists are dealing with myriad policy issues stemming from the generational healthcare reform legislation colloquially referred to as “Obamacare,” policy experts at HM14 noted that hospitalists can help control how changes will be incorporated into day-to-day care delivery.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future,” said Dr. Greeno, chief medical officer of Cogent Healthcare in Brentwood, Tenn., and chair of SHM’s Public Policy Committee. “They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

At a base level, the ACA is codifying and prodding healthcare’s move away from fee-for-service payments to compensation based on the health of a given population. Over time, that shift will reward value, not simply pay up for procedures and tests, Dr. Greeno said.

As an example, he explained, “If we prevent a readmission in a fee-for-service world, there are hospitals that tell us that that actually hurts them; they need that admission. In a population health environment ... if you prevent a readmission, that’s wonderful thing. That’s a hospitalization that did not occur. That creates tremendous value.”

SHM CEO Larry Wellikson, MD, SFHM, said hospitalists not only provide that value on the ground, but also have a strong voice in Washington, D.C. That is especially true with hospitalist Patrick Conway, MD, MSc, FAAP, MHM, who serves as chief medical officer for the Centers for Medicare & Medicaid Services (CMS). Dr. Conway is the former chair of SHM’s Public Policy Committee.

“We’re a young organization with no budget and no power, and we get to have a face-to-face conversation with the guy that’s running Medicare,” Dr. Wellikson said. “Five or six hospitalists from SHM sit on our Public Policy Committee and think about how to fix the observation unit, and the next thing you know it becomes [part] of the regulations and changes things. We’re not your ordinary society.”

Robert Wachter, MD, MHM, also noted that the specialty is waiting to see if the U.S. Senate will approve President Obama’s nomination of Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has been a strong supporter of the ACA, but a vote on his approval is being held up by Congress members who are concerned he will use the position as a bully pulpit against gun control, a claim he has denied.

Dr. Wellikson added that when lobbying for continued changes to healthcare rules, SHM tries to focus on providing assistance, not asking for handouts. That will likely be a big focus next year, as the annual meeting returns to a suburb of Washington, D.C., with an expectation that hundreds of hospitalists will participate in the “Hospitalists on the Hill” advocacy event.

“We never go to Washington and ask for more power for hospitals or more money for hospitalists,” Dr. Wellikson said. “When we go to Washington, we say, ‘Things are changing in the system. How can we be a part of that change?’

“And that makes us very, very different.”

To be sure, not everyone at HM14 had the rosiest view on Obamacare and how it will play out in the next few years from a policy perspective. Scott Gottlieb, MD, a practicing physician, U.S. Food and Drug Administration alumni, and American Enterprise Institute fellow, said that the financial repercussions of reforms will reduce costs.

“That might affect hospitalist employment, or the hospitalists are going to have to take on new responsibilities to try to make up for services that hospitals might be shedding,” Dr. Gottlieb said. “But if I were trying to pick a growth industry right now, it would be restructuring distressed hospitals. That’s what’s going to happen in five years.”

Dr. Gottlieb, a frequent contributor to Fox News, said that while many political conservatives argue that Obamacare is driving all of the healthcare problems, many underlying components of the ACA have support from Republicans and Democrats, including proposed reforms to Medicare’s sustainable growth rate (SGR) formula.

“It’s hard to just blame Obamacare for this,” he said. “The SGR bill, which is coming out of a Republican-led House and has bipartisan support, codifies major elements of Obamacare that, frankly, I’ve been criticizing for the last four years.”

Dr. Gottlieb believes that risk sharing has to improve for healthcare reform to be embraced by the best-performing doctors. Bundled payments, for example, shift nearly all of the payment risk onto physicians, because their revenue will be capped at a point, regardless of the cost of services rendered, Dr. Gottlieb said.

“I think, ultimately, as physicians, we should be fearful of payment models that put a lot of the financial risk on physicians without ways to offset some of that risk and without tools to manage it well,” he added.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future. They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

—Dr. Greeno

HM14 keynote speaker and healthcare futurist Ian Morrison, PhD, said he believes that Obamacare will spur local health systems to merge, until just 100 to 200 regional or super-regional systems exist. Consolidation, he noted, ultimately will reduce the number of health systems to between 50 and 75 nationwide.

“Everybody understands we need to reform the delivery system,” Dr. Morrison said, adding that he wants hospitalists to “have an increased interest in public policy and advocate for the things that we believe in, which is better patient care and better outcomes for patients.”

With reference to Dr. Greeno’s analogy that Obamacare is a baseball game in the first inning, Dr. Morrison said he believes that all HM14 attendees will deal with policy implications of the ACA until the end of their careers. And while those changes are often frustrating, he said one of the core themes—a more unified healthcare delivery system focused on value—is for the greater good.

“The unintended consequences are going to be felt for decades,” he said. “But there are parts of it that would be very hard for anybody to disagree with: that we need to have more alignment in terms of other providers and with hospitals.”

LAS VEGAS—As America’s favorite pastime began a new season, hospitalists from all parts of the country engaged in a variety of healthcare policy discussions at HM14. That’s why the baseball analogy that SHM advocacy guru Ron Greeno, MD, MHM, used to describe how far along the industry is in implementing the Affordable Care Act (ACA) was particularly fitting: “We’re in the first inning,” he said.

So, while hospitalists are dealing with myriad policy issues stemming from the generational healthcare reform legislation colloquially referred to as “Obamacare,” policy experts at HM14 noted that hospitalists can help control how changes will be incorporated into day-to-day care delivery.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future,” said Dr. Greeno, chief medical officer of Cogent Healthcare in Brentwood, Tenn., and chair of SHM’s Public Policy Committee. “They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

At a base level, the ACA is codifying and prodding healthcare’s move away from fee-for-service payments to compensation based on the health of a given population. Over time, that shift will reward value, not simply pay up for procedures and tests, Dr. Greeno said.

As an example, he explained, “If we prevent a readmission in a fee-for-service world, there are hospitals that tell us that that actually hurts them; they need that admission. In a population health environment ... if you prevent a readmission, that’s wonderful thing. That’s a hospitalization that did not occur. That creates tremendous value.”

SHM CEO Larry Wellikson, MD, SFHM, said hospitalists not only provide that value on the ground, but also have a strong voice in Washington, D.C. That is especially true with hospitalist Patrick Conway, MD, MSc, FAAP, MHM, who serves as chief medical officer for the Centers for Medicare & Medicaid Services (CMS). Dr. Conway is the former chair of SHM’s Public Policy Committee.

“We’re a young organization with no budget and no power, and we get to have a face-to-face conversation with the guy that’s running Medicare,” Dr. Wellikson said. “Five or six hospitalists from SHM sit on our Public Policy Committee and think about how to fix the observation unit, and the next thing you know it becomes [part] of the regulations and changes things. We’re not your ordinary society.”

Robert Wachter, MD, MHM, also noted that the specialty is waiting to see if the U.S. Senate will approve President Obama’s nomination of Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has been a strong supporter of the ACA, but a vote on his approval is being held up by Congress members who are concerned he will use the position as a bully pulpit against gun control, a claim he has denied.

Dr. Wellikson added that when lobbying for continued changes to healthcare rules, SHM tries to focus on providing assistance, not asking for handouts. That will likely be a big focus next year, as the annual meeting returns to a suburb of Washington, D.C., with an expectation that hundreds of hospitalists will participate in the “Hospitalists on the Hill” advocacy event.

“We never go to Washington and ask for more power for hospitals or more money for hospitalists,” Dr. Wellikson said. “When we go to Washington, we say, ‘Things are changing in the system. How can we be a part of that change?’

“And that makes us very, very different.”

To be sure, not everyone at HM14 had the rosiest view on Obamacare and how it will play out in the next few years from a policy perspective. Scott Gottlieb, MD, a practicing physician, U.S. Food and Drug Administration alumni, and American Enterprise Institute fellow, said that the financial repercussions of reforms will reduce costs.

“That might affect hospitalist employment, or the hospitalists are going to have to take on new responsibilities to try to make up for services that hospitals might be shedding,” Dr. Gottlieb said. “But if I were trying to pick a growth industry right now, it would be restructuring distressed hospitals. That’s what’s going to happen in five years.”

Dr. Gottlieb, a frequent contributor to Fox News, said that while many political conservatives argue that Obamacare is driving all of the healthcare problems, many underlying components of the ACA have support from Republicans and Democrats, including proposed reforms to Medicare’s sustainable growth rate (SGR) formula.

“It’s hard to just blame Obamacare for this,” he said. “The SGR bill, which is coming out of a Republican-led House and has bipartisan support, codifies major elements of Obamacare that, frankly, I’ve been criticizing for the last four years.”

Dr. Gottlieb believes that risk sharing has to improve for healthcare reform to be embraced by the best-performing doctors. Bundled payments, for example, shift nearly all of the payment risk onto physicians, because their revenue will be capped at a point, regardless of the cost of services rendered, Dr. Gottlieb said.

“I think, ultimately, as physicians, we should be fearful of payment models that put a lot of the financial risk on physicians without ways to offset some of that risk and without tools to manage it well,” he added.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future. They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

—Dr. Greeno

HM14 keynote speaker and healthcare futurist Ian Morrison, PhD, said he believes that Obamacare will spur local health systems to merge, until just 100 to 200 regional or super-regional systems exist. Consolidation, he noted, ultimately will reduce the number of health systems to between 50 and 75 nationwide.

“Everybody understands we need to reform the delivery system,” Dr. Morrison said, adding that he wants hospitalists to “have an increased interest in public policy and advocate for the things that we believe in, which is better patient care and better outcomes for patients.”

With reference to Dr. Greeno’s analogy that Obamacare is a baseball game in the first inning, Dr. Morrison said he believes that all HM14 attendees will deal with policy implications of the ACA until the end of their careers. And while those changes are often frustrating, he said one of the core themes—a more unified healthcare delivery system focused on value—is for the greater good.

“The unintended consequences are going to be felt for decades,” he said. “But there are parts of it that would be very hard for anybody to disagree with: that we need to have more alignment in terms of other providers and with hospitals.”

LAS VEGAS—As America’s favorite pastime began a new season, hospitalists from all parts of the country engaged in a variety of healthcare policy discussions at HM14. That’s why the baseball analogy that SHM advocacy guru Ron Greeno, MD, MHM, used to describe how far along the industry is in implementing the Affordable Care Act (ACA) was particularly fitting: “We’re in the first inning,” he said.

So, while hospitalists are dealing with myriad policy issues stemming from the generational healthcare reform legislation colloquially referred to as “Obamacare,” policy experts at HM14 noted that hospitalists can help control how changes will be incorporated into day-to-day care delivery.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future,” said Dr. Greeno, chief medical officer of Cogent Healthcare in Brentwood, Tenn., and chair of SHM’s Public Policy Committee. “They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

At a base level, the ACA is codifying and prodding healthcare’s move away from fee-for-service payments to compensation based on the health of a given population. Over time, that shift will reward value, not simply pay up for procedures and tests, Dr. Greeno said.

As an example, he explained, “If we prevent a readmission in a fee-for-service world, there are hospitals that tell us that that actually hurts them; they need that admission. In a population health environment ... if you prevent a readmission, that’s wonderful thing. That’s a hospitalization that did not occur. That creates tremendous value.”

SHM CEO Larry Wellikson, MD, SFHM, said hospitalists not only provide that value on the ground, but also have a strong voice in Washington, D.C. That is especially true with hospitalist Patrick Conway, MD, MSc, FAAP, MHM, who serves as chief medical officer for the Centers for Medicare & Medicaid Services (CMS). Dr. Conway is the former chair of SHM’s Public Policy Committee.

“We’re a young organization with no budget and no power, and we get to have a face-to-face conversation with the guy that’s running Medicare,” Dr. Wellikson said. “Five or six hospitalists from SHM sit on our Public Policy Committee and think about how to fix the observation unit, and the next thing you know it becomes [part] of the regulations and changes things. We’re not your ordinary society.”

Robert Wachter, MD, MHM, also noted that the specialty is waiting to see if the U.S. Senate will approve President Obama’s nomination of Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has been a strong supporter of the ACA, but a vote on his approval is being held up by Congress members who are concerned he will use the position as a bully pulpit against gun control, a claim he has denied.

Dr. Wellikson added that when lobbying for continued changes to healthcare rules, SHM tries to focus on providing assistance, not asking for handouts. That will likely be a big focus next year, as the annual meeting returns to a suburb of Washington, D.C., with an expectation that hundreds of hospitalists will participate in the “Hospitalists on the Hill” advocacy event.

“We never go to Washington and ask for more power for hospitals or more money for hospitalists,” Dr. Wellikson said. “When we go to Washington, we say, ‘Things are changing in the system. How can we be a part of that change?’

“And that makes us very, very different.”

To be sure, not everyone at HM14 had the rosiest view on Obamacare and how it will play out in the next few years from a policy perspective. Scott Gottlieb, MD, a practicing physician, U.S. Food and Drug Administration alumni, and American Enterprise Institute fellow, said that the financial repercussions of reforms will reduce costs.

“That might affect hospitalist employment, or the hospitalists are going to have to take on new responsibilities to try to make up for services that hospitals might be shedding,” Dr. Gottlieb said. “But if I were trying to pick a growth industry right now, it would be restructuring distressed hospitals. That’s what’s going to happen in five years.”

Dr. Gottlieb, a frequent contributor to Fox News, said that while many political conservatives argue that Obamacare is driving all of the healthcare problems, many underlying components of the ACA have support from Republicans and Democrats, including proposed reforms to Medicare’s sustainable growth rate (SGR) formula.

“It’s hard to just blame Obamacare for this,” he said. “The SGR bill, which is coming out of a Republican-led House and has bipartisan support, codifies major elements of Obamacare that, frankly, I’ve been criticizing for the last four years.”

Dr. Gottlieb believes that risk sharing has to improve for healthcare reform to be embraced by the best-performing doctors. Bundled payments, for example, shift nearly all of the payment risk onto physicians, because their revenue will be capped at a point, regardless of the cost of services rendered, Dr. Gottlieb said.

“I think, ultimately, as physicians, we should be fearful of payment models that put a lot of the financial risk on physicians without ways to offset some of that risk and without tools to manage it well,” he added.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future. They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

—Dr. Greeno

HM14 keynote speaker and healthcare futurist Ian Morrison, PhD, said he believes that Obamacare will spur local health systems to merge, until just 100 to 200 regional or super-regional systems exist. Consolidation, he noted, ultimately will reduce the number of health systems to between 50 and 75 nationwide.

“Everybody understands we need to reform the delivery system,” Dr. Morrison said, adding that he wants hospitalists to “have an increased interest in public policy and advocate for the things that we believe in, which is better patient care and better outcomes for patients.”

With reference to Dr. Greeno’s analogy that Obamacare is a baseball game in the first inning, Dr. Morrison said he believes that all HM14 attendees will deal with policy implications of the ACA until the end of their careers. And while those changes are often frustrating, he said one of the core themes—a more unified healthcare delivery system focused on value—is for the greater good.

“The unintended consequences are going to be felt for decades,” he said. “But there are parts of it that would be very hard for anybody to disagree with: that we need to have more alignment in terms of other providers and with hospitals.”

LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.

You could almost hear the bell go off in her head.

“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”

That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.

For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.

The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”

Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.

Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can. We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

–Dr. Wellikson

“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”

Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”

SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”

SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.

“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.

“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”

Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.

Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.

“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”

LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.

You could almost hear the bell go off in her head.

“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”

That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.

For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.

The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”

Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.

Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can. We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

–Dr. Wellikson

“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”

Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”

SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”

SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.

“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.

“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”

Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.

Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.

“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”

LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.

You could almost hear the bell go off in her head.

“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”

That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.

For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.

The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”

Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.

Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can. We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

–Dr. Wellikson

“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”

Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”

SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”

SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.

“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.

“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”

Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.

Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.

“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”

"“Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice."

LAS VEGAS—Bob Wachter, MD, MHM, hyped the final six minutes of his annual meeting address as something hospitalists at HM14 conference wouldn’t forget. As usual, he was right.

The man who helped coin the term “hospitalist,” and whose penultimate pep talk has come to signal the unofficial end of SHM’s annual meeting, finished his plenary on the confab’s last day and returned minutes later in a white suit, yellowed wig, and sunglasses worthy of the man he was portraying: Elton John.

After enjoying Dr. Wachter’s retooled lyrics—in which “Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice.

“That was just phenomenal,” said hospitalist Kevin Gilroy, MD, of Greenville, S.C. “What other conference does that? You find another society that is that down to Earth.”—RQ

"“Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice."

LAS VEGAS—Bob Wachter, MD, MHM, hyped the final six minutes of his annual meeting address as something hospitalists at HM14 conference wouldn’t forget. As usual, he was right.

The man who helped coin the term “hospitalist,” and whose penultimate pep talk has come to signal the unofficial end of SHM’s annual meeting, finished his plenary on the confab’s last day and returned minutes later in a white suit, yellowed wig, and sunglasses worthy of the man he was portraying: Elton John.

After enjoying Dr. Wachter’s retooled lyrics—in which “Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice.

“That was just phenomenal,” said hospitalist Kevin Gilroy, MD, of Greenville, S.C. “What other conference does that? You find another society that is that down to Earth.”—RQ

"“Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice."

LAS VEGAS—Bob Wachter, MD, MHM, hyped the final six minutes of his annual meeting address as something hospitalists at HM14 conference wouldn’t forget. As usual, he was right.

The man who helped coin the term “hospitalist,” and whose penultimate pep talk has come to signal the unofficial end of SHM’s annual meeting, finished his plenary on the confab’s last day and returned minutes later in a white suit, yellowed wig, and sunglasses worthy of the man he was portraying: Elton John.

After enjoying Dr. Wachter’s retooled lyrics—in which “Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice.

“That was just phenomenal,” said hospitalist Kevin Gilroy, MD, of Greenville, S.C. “What other conference does that? You find another society that is that down to Earth.”—RQ

LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.

“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”

In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.

“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.

The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.

The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.

“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

“A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

–Dr. Gottlieb

Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”

Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.

“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”

The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.

Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.

“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.

“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

“What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

–Dr. Kealey

And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.

Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.

“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.

“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”

LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.

“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”

In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.

“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.

The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.

The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.

“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

“A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

–Dr. Gottlieb

Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”

Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.

“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”

The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.

Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.

“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.

“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

“What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

–Dr. Kealey

And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.

Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.

“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.

“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”

LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.

“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”

In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.

“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.

The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.

The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.

“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

“A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

–Dr. Gottlieb

Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”

Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.

“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”

The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.

Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.

“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.

“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

“What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

–Dr. Kealey

And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.

Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.

“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.

“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”

Dr. Howell

Together with more than 3,000 hospitalists at its annual meeting, SHM celebrated the recipients of its annual Awards of Excellence and three new Masters in Hospital Medicine (MHM), the highest honor in hospital medicine. They were honored in a special plenary session at HM14 in Las Vegas on March 26, along with SHM’s first chapter award winners.

Dr. Howell

HM14 was the largest event in the history of the hospitalist movement. And the specialty continues to grow; SHM estimates that there are now more than 44,000 hospitalists nationwide.

“We are thrilled to celebrate the achievements of the many hospitalists who are moving the specialty forward and demonstrating how all hospitalists can provide exceptional care for hospitalized patients,” says Eric Howell, MD, SFHM, SHM’s immediate past president, who presented the awards and the certificates for the Masters in Hospital Medicine.

“In a new era of American healthcare, hospitalists have become one of the greatest advocates for improvement within the hospital, and SHM looks forward to providing them with the resources to make those changes for the better.”

2014 Awards of Excellence

Each year, SHM recognizes best practices in a number of fields within the growing specialty of hospital medicine through its Awards of Excellence. In 2014, the society is introducing a seventh award: the SHM Excellence in Humanitarian Service Award.

Dr. Simone

Kenneth Simone, DO, SFHM, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, is the 2014 recipient of SHM’s Award of Excellence for Outstanding Service in Hospital Medicine. This award recognizes exceptional service within the discipline of hospital medicine. Dr. Simone’s innovative approach to hospital medicine has had a broad national impact, working to increase the growth, development, and success of the hospital medicine specialty.

Dr. Metlay

Joshua Metlay, MD, PhD, FACP, chief of the division of general internal medicine at Massachusetts General Hospital and professor of medicine at Harvard Medical School in Boston, is the recipient of the 2014 Excellence in Research Award, which recognizes outstanding achievement by a researcher in the field of hospital medicine. Dr. Metlay’s research focuses on areas important to hospitalists and their patients: the epidemiology and improved treatment of respiratory tract infections.

Dr. Mattison

Melissa Mattison, MD, FACP, SFHM, associate chief of the section of hospital medicine at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, Boston, will receive the 2014 Award for Clinical Excellence, an award that recognizes exemplary clinical service in hospital medicine. As a geriatrician and hospitalist, Dr. Mattison focuses her research and clinical innovation efforts on improving care for hospitalized elders. She is at the forefront because she is developing best practices for implementation of clinical innovations to benefit older, hospitalized patients.

Dr. Dressler

Daniel Dressler, MD, MSc, FACP, SFHM, has been selected as the 2014 recipient of SHM’s Award for Excellence in Teaching. Dr. Dressler serves as professor of medicine, hospital medicine associate division director for education, and director of internal medicine teaching services at Emory University Hospital; associate program director for the J. Willis Hurst Internal Medicine Residency Program; and Medical Student Semmelweis Society Advisor at Emory University’s School of Medicine in Atlanta, Georgia. The Award for Excellence in Teaching is earned by hospitalists who have demonstrated outstanding teaching acumen, serving as educators, role models, and mentors to other hospitalists, residents, medical students, or healthcare professionals.

Dr. Swanson

Michelle (Mikkii) Swanson, DNP, MSN, RN, ACM, SFHM, Director of Hospitalist Services at Community Health Systems Professional Services Corporation in Franklin, Tenn., will receive the 2014 Excellence in Hospital Medicine for Non-Physicians Award. This honor is reserved for those committed and talented professionals—including those with the Doctor of Nursing Practice designation—who contribute significantly to the success of the hospital medicine team but are not physicians.

The Improving Adherence to Evidence-Based Recommendations for Common Serious Childhood Infections team at Cincinnati Children’s Hospital Medical Center is the 2014 recipient of SHM’s Award of Excellence in Teamwork in Quality Improvement. The team, led by Samir S. Shah, MD, MSCE, FHM, division of hospital medicine at Cincinnati Children’s Hospital Medical Center, has earned this award for their commitment to enhancing teamwork among physicians, nurses, and other healthcare providers in an effort to ultimately improve outcomes for hospitalized patients.

Dr. Reich

Patience Reich, MD, SFHM, has been selected as the first-ever recipient of SHM’s Award for Excellence in Humanitarian Service. This award is intended to highlight the volunteer effort SHM members give to at-risk populations, above and beyond the hospital care provided to patients and their families during daily activities as hospitalists. Dr. Reich’s humanitarian work spans her medical career and consists of providing medical care and service in Africa, Asia, Central and South America, the United States, and Haiti, where she will be returning in April 2014 with four professional colleagues and 25 medical students from Wake Forest University School of Medicine in Winston-Salem, N.C.

2014 Masters in Hospital Medicine

Each year, SHM awards the Masters in Hospital Medicine—its highest honor—to a select group of hospitalists who have distinguished themselves uniquely through their contributions to hospital medicine and healthcare as a whole. Considered the “Hall of Fame” of the hospital medicine movement, the 2014 Masters join thirteen other MHMs in the specialty, for a total of 16 Masters.

Dr. Conway

Patrick Conway, MD, MSc, MHM, FAAP, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), has been elected a Master in Hospital Medicine in recognition of his tireless commitment to reshaping the nation’s healthcare system to provide exceptional care to hospitalized patients—and all Americans. He also serves as director of the Center for Clinical Standards and Quality, director of the Center for Medicare and Medicaid Innovation, and deputy administrator for Innovation and Quality for CMS.

Dr. Pantilat

Steven Z. Pantilat, MD, MHM, has been elected a Master in Hospital Medicine in honor of his foundational leadership in the hospital medicine movement and his pioneering work in improving care for seriously ill and dying patients. He is a professor of clinical medicine in the department of medicine at the University of California, San Francisco, the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care, and the founding director of the UCSF Palliative Care Program.

Dr. Percelay

Jack Martin Percelay, MD, MPH, FAAP, MHM, has been elected a Master in Hospital Medicine in recognition of his national leadership in shaping the pediatric hospital medicine specialty and his ability to advance the concerns of hospitalized children and hospitalists everywhere. Dr. Percelay is a pediatric intensive care hospitalist at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician assistant studies at the Pace University College of Health Professions in New York City.

Similar to SHM’s Fellows in Hospital Medicine (FHM) and Senior Fellows in Hospital Medicine (SFHM), the Masters in Hospital Medicine have earned the right to append “MHM” to their names as a designation.

New Board Leadership

As part of its governance process, SHM members elect new directors to its board. This year, SHM is pleased to welcome the following new members of the Board of Directors:

Dr. Greeno

Ron Greeno, MD, MHM, FCCP, founder of Cogent Healthcare and Cogent’s Executive VP for Strategy and Innovation, and

Dr. Scheurer

Danielle Scheurer, MD, MSCR, SFHM, clinical hospitalist and the chief quality officer at the Medical University of South Carolina in Charleston, S.C.

Brendon Shank is SHM’s associate vice president of communications.

Dr. Howell

Together with more than 3,000 hospitalists at its annual meeting, SHM celebrated the recipients of its annual Awards of Excellence and three new Masters in Hospital Medicine (MHM), the highest honor in hospital medicine. They were honored in a special plenary session at HM14 in Las Vegas on March 26, along with SHM’s first chapter award winners.

Dr. Howell

HM14 was the largest event in the history of the hospitalist movement. And the specialty continues to grow; SHM estimates that there are now more than 44,000 hospitalists nationwide.

“We are thrilled to celebrate the achievements of the many hospitalists who are moving the specialty forward and demonstrating how all hospitalists can provide exceptional care for hospitalized patients,” says Eric Howell, MD, SFHM, SHM’s immediate past president, who presented the awards and the certificates for the Masters in Hospital Medicine.

“In a new era of American healthcare, hospitalists have become one of the greatest advocates for improvement within the hospital, and SHM looks forward to providing them with the resources to make those changes for the better.”

2014 Awards of Excellence

Each year, SHM recognizes best practices in a number of fields within the growing specialty of hospital medicine through its Awards of Excellence. In 2014, the society is introducing a seventh award: the SHM Excellence in Humanitarian Service Award.

Dr. Simone

Kenneth Simone, DO, SFHM, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, is the 2014 recipient of SHM’s Award of Excellence for Outstanding Service in Hospital Medicine. This award recognizes exceptional service within the discipline of hospital medicine. Dr. Simone’s innovative approach to hospital medicine has had a broad national impact, working to increase the growth, development, and success of the hospital medicine specialty.

Dr. Metlay

Joshua Metlay, MD, PhD, FACP, chief of the division of general internal medicine at Massachusetts General Hospital and professor of medicine at Harvard Medical School in Boston, is the recipient of the 2014 Excellence in Research Award, which recognizes outstanding achievement by a researcher in the field of hospital medicine. Dr. Metlay’s research focuses on areas important to hospitalists and their patients: the epidemiology and improved treatment of respiratory tract infections.

Dr. Mattison

Melissa Mattison, MD, FACP, SFHM, associate chief of the section of hospital medicine at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, Boston, will receive the 2014 Award for Clinical Excellence, an award that recognizes exemplary clinical service in hospital medicine. As a geriatrician and hospitalist, Dr. Mattison focuses her research and clinical innovation efforts on improving care for hospitalized elders. She is at the forefront because she is developing best practices for implementation of clinical innovations to benefit older, hospitalized patients.

Dr. Dressler

Daniel Dressler, MD, MSc, FACP, SFHM, has been selected as the 2014 recipient of SHM’s Award for Excellence in Teaching. Dr. Dressler serves as professor of medicine, hospital medicine associate division director for education, and director of internal medicine teaching services at Emory University Hospital; associate program director for the J. Willis Hurst Internal Medicine Residency Program; and Medical Student Semmelweis Society Advisor at Emory University’s School of Medicine in Atlanta, Georgia. The Award for Excellence in Teaching is earned by hospitalists who have demonstrated outstanding teaching acumen, serving as educators, role models, and mentors to other hospitalists, residents, medical students, or healthcare professionals.

Dr. Swanson

Michelle (Mikkii) Swanson, DNP, MSN, RN, ACM, SFHM, Director of Hospitalist Services at Community Health Systems Professional Services Corporation in Franklin, Tenn., will receive the 2014 Excellence in Hospital Medicine for Non-Physicians Award. This honor is reserved for those committed and talented professionals—including those with the Doctor of Nursing Practice designation—who contribute significantly to the success of the hospital medicine team but are not physicians.

The Improving Adherence to Evidence-Based Recommendations for Common Serious Childhood Infections team at Cincinnati Children’s Hospital Medical Center is the 2014 recipient of SHM’s Award of Excellence in Teamwork in Quality Improvement. The team, led by Samir S. Shah, MD, MSCE, FHM, division of hospital medicine at Cincinnati Children’s Hospital Medical Center, has earned this award for their commitment to enhancing teamwork among physicians, nurses, and other healthcare providers in an effort to ultimately improve outcomes for hospitalized patients.

Dr. Reich

Patience Reich, MD, SFHM, has been selected as the first-ever recipient of SHM’s Award for Excellence in Humanitarian Service. This award is intended to highlight the volunteer effort SHM members give to at-risk populations, above and beyond the hospital care provided to patients and their families during daily activities as hospitalists. Dr. Reich’s humanitarian work spans her medical career and consists of providing medical care and service in Africa, Asia, Central and South America, the United States, and Haiti, where she will be returning in April 2014 with four professional colleagues and 25 medical students from Wake Forest University School of Medicine in Winston-Salem, N.C.

2014 Masters in Hospital Medicine

Each year, SHM awards the Masters in Hospital Medicine—its highest honor—to a select group of hospitalists who have distinguished themselves uniquely through their contributions to hospital medicine and healthcare as a whole. Considered the “Hall of Fame” of the hospital medicine movement, the 2014 Masters join thirteen other MHMs in the specialty, for a total of 16 Masters.

Dr. Conway

Patrick Conway, MD, MSc, MHM, FAAP, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), has been elected a Master in Hospital Medicine in recognition of his tireless commitment to reshaping the nation’s healthcare system to provide exceptional care to hospitalized patients—and all Americans. He also serves as director of the Center for Clinical Standards and Quality, director of the Center for Medicare and Medicaid Innovation, and deputy administrator for Innovation and Quality for CMS.

Dr. Pantilat

Steven Z. Pantilat, MD, MHM, has been elected a Master in Hospital Medicine in honor of his foundational leadership in the hospital medicine movement and his pioneering work in improving care for seriously ill and dying patients. He is a professor of clinical medicine in the department of medicine at the University of California, San Francisco, the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care, and the founding director of the UCSF Palliative Care Program.

Dr. Percelay

Jack Martin Percelay, MD, MPH, FAAP, MHM, has been elected a Master in Hospital Medicine in recognition of his national leadership in shaping the pediatric hospital medicine specialty and his ability to advance the concerns of hospitalized children and hospitalists everywhere. Dr. Percelay is a pediatric intensive care hospitalist at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician assistant studies at the Pace University College of Health Professions in New York City.

Similar to SHM’s Fellows in Hospital Medicine (FHM) and Senior Fellows in Hospital Medicine (SFHM), the Masters in Hospital Medicine have earned the right to append “MHM” to their names as a designation.

New Board Leadership

As part of its governance process, SHM members elect new directors to its board. This year, SHM is pleased to welcome the following new members of the Board of Directors:

Dr. Greeno

Ron Greeno, MD, MHM, FCCP, founder of Cogent Healthcare and Cogent’s Executive VP for Strategy and Innovation, and

Dr. Scheurer

Danielle Scheurer, MD, MSCR, SFHM, clinical hospitalist and the chief quality officer at the Medical University of South Carolina in Charleston, S.C.

Brendon Shank is SHM’s associate vice president of communications.

Dr. Howell

Together with more than 3,000 hospitalists at its annual meeting, SHM celebrated the recipients of its annual Awards of Excellence and three new Masters in Hospital Medicine (MHM), the highest honor in hospital medicine. They were honored in a special plenary session at HM14 in Las Vegas on March 26, along with SHM’s first chapter award winners.

Dr. Howell

HM14 was the largest event in the history of the hospitalist movement. And the specialty continues to grow; SHM estimates that there are now more than 44,000 hospitalists nationwide.

“We are thrilled to celebrate the achievements of the many hospitalists who are moving the specialty forward and demonstrating how all hospitalists can provide exceptional care for hospitalized patients,” says Eric Howell, MD, SFHM, SHM’s immediate past president, who presented the awards and the certificates for the Masters in Hospital Medicine.

“In a new era of American healthcare, hospitalists have become one of the greatest advocates for improvement within the hospital, and SHM looks forward to providing them with the resources to make those changes for the better.”

2014 Awards of Excellence

Each year, SHM recognizes best practices in a number of fields within the growing specialty of hospital medicine through its Awards of Excellence. In 2014, the society is introducing a seventh award: the SHM Excellence in Humanitarian Service Award.

Dr. Simone

Kenneth Simone, DO, SFHM, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, is the 2014 recipient of SHM’s Award of Excellence for Outstanding Service in Hospital Medicine. This award recognizes exceptional service within the discipline of hospital medicine. Dr. Simone’s innovative approach to hospital medicine has had a broad national impact, working to increase the growth, development, and success of the hospital medicine specialty.

Dr. Metlay

Joshua Metlay, MD, PhD, FACP, chief of the division of general internal medicine at Massachusetts General Hospital and professor of medicine at Harvard Medical School in Boston, is the recipient of the 2014 Excellence in Research Award, which recognizes outstanding achievement by a researcher in the field of hospital medicine. Dr. Metlay’s research focuses on areas important to hospitalists and their patients: the epidemiology and improved treatment of respiratory tract infections.

Dr. Mattison

Melissa Mattison, MD, FACP, SFHM, associate chief of the section of hospital medicine at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, Boston, will receive the 2014 Award for Clinical Excellence, an award that recognizes exemplary clinical service in hospital medicine. As a geriatrician and hospitalist, Dr. Mattison focuses her research and clinical innovation efforts on improving care for hospitalized elders. She is at the forefront because she is developing best practices for implementation of clinical innovations to benefit older, hospitalized patients.

Dr. Dressler

Daniel Dressler, MD, MSc, FACP, SFHM, has been selected as the 2014 recipient of SHM’s Award for Excellence in Teaching. Dr. Dressler serves as professor of medicine, hospital medicine associate division director for education, and director of internal medicine teaching services at Emory University Hospital; associate program director for the J. Willis Hurst Internal Medicine Residency Program; and Medical Student Semmelweis Society Advisor at Emory University’s School of Medicine in Atlanta, Georgia. The Award for Excellence in Teaching is earned by hospitalists who have demonstrated outstanding teaching acumen, serving as educators, role models, and mentors to other hospitalists, residents, medical students, or healthcare professionals.

Dr. Swanson

Michelle (Mikkii) Swanson, DNP, MSN, RN, ACM, SFHM, Director of Hospitalist Services at Community Health Systems Professional Services Corporation in Franklin, Tenn., will receive the 2014 Excellence in Hospital Medicine for Non-Physicians Award. This honor is reserved for those committed and talented professionals—including those with the Doctor of Nursing Practice designation—who contribute significantly to the success of the hospital medicine team but are not physicians.

The Improving Adherence to Evidence-Based Recommendations for Common Serious Childhood Infections team at Cincinnati Children’s Hospital Medical Center is the 2014 recipient of SHM’s Award of Excellence in Teamwork in Quality Improvement. The team, led by Samir S. Shah, MD, MSCE, FHM, division of hospital medicine at Cincinnati Children’s Hospital Medical Center, has earned this award for their commitment to enhancing teamwork among physicians, nurses, and other healthcare providers in an effort to ultimately improve outcomes for hospitalized patients.

Dr. Reich

Patience Reich, MD, SFHM, has been selected as the first-ever recipient of SHM’s Award for Excellence in Humanitarian Service. This award is intended to highlight the volunteer effort SHM members give to at-risk populations, above and beyond the hospital care provided to patients and their families during daily activities as hospitalists. Dr. Reich’s humanitarian work spans her medical career and consists of providing medical care and service in Africa, Asia, Central and South America, the United States, and Haiti, where she will be returning in April 2014 with four professional colleagues and 25 medical students from Wake Forest University School of Medicine in Winston-Salem, N.C.

2014 Masters in Hospital Medicine

Each year, SHM awards the Masters in Hospital Medicine—its highest honor—to a select group of hospitalists who have distinguished themselves uniquely through their contributions to hospital medicine and healthcare as a whole. Considered the “Hall of Fame” of the hospital medicine movement, the 2014 Masters join thirteen other MHMs in the specialty, for a total of 16 Masters.

Dr. Conway

Patrick Conway, MD, MSc, MHM, FAAP, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), has been elected a Master in Hospital Medicine in recognition of his tireless commitment to reshaping the nation’s healthcare system to provide exceptional care to hospitalized patients—and all Americans. He also serves as director of the Center for Clinical Standards and Quality, director of the Center for Medicare and Medicaid Innovation, and deputy administrator for Innovation and Quality for CMS.

Dr. Pantilat

Steven Z. Pantilat, MD, MHM, has been elected a Master in Hospital Medicine in honor of his foundational leadership in the hospital medicine movement and his pioneering work in improving care for seriously ill and dying patients. He is a professor of clinical medicine in the department of medicine at the University of California, San Francisco, the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care, and the founding director of the UCSF Palliative Care Program.

Dr. Percelay

Jack Martin Percelay, MD, MPH, FAAP, MHM, has been elected a Master in Hospital Medicine in recognition of his national leadership in shaping the pediatric hospital medicine specialty and his ability to advance the concerns of hospitalized children and hospitalists everywhere. Dr. Percelay is a pediatric intensive care hospitalist at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician assistant studies at the Pace University College of Health Professions in New York City.

Similar to SHM’s Fellows in Hospital Medicine (FHM) and Senior Fellows in Hospital Medicine (SFHM), the Masters in Hospital Medicine have earned the right to append “MHM” to their names as a designation.

New Board Leadership

As part of its governance process, SHM members elect new directors to its board. This year, SHM is pleased to welcome the following new members of the Board of Directors:

Dr. Greeno

Ron Greeno, MD, MHM, FCCP, founder of Cogent Healthcare and Cogent’s Executive VP for Strategy and Innovation, and

Dr. Scheurer

Danielle Scheurer, MD, MSCR, SFHM, clinical hospitalist and the chief quality officer at the Medical University of South Carolina in Charleston, S.C.

Brendon Shank is SHM’s associate vice president of communications.