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Hospital Medicine Blends Academic, Clinical Pursuits to Create Optimal Career Path
Are you attracted to research but not sure if it’s your sole calling as a prospective hospitalist? Whether you think you might want to steer quality improvement (QI) studies in the community setting or veer toward an academic/research career, hospital medicine offers an array of paths to career satisfaction.
“There is so much room in hospital medicine to find your research niche,” says Luci K. Leykum, MD, MBA, MSc, SFHM, hospital medicine division chief and associate dean for clinical affairs at University of Texas Health Science Center in San Antonio. As chair of SHM’s Research Committee, Dr. Leykum can attest to the range of hospitalists’ research pursuits: from basic science (what biomarkers best predict poor outcomes in patients with acute lung injury?) to care organization (are hospitalist schedules and workload associated with patient outcomes?) to implementation (how do we most effectively implement best practices for care transitions?) studies.1-6
In addition to Dr. Leykum, The Hospitalist consulted Vineet Arora, MD, MPP, FACP, SFHM, associate professor of medicine at the University of Chicago and chair of SHM’s Physicians in Training Committee, and Margaret Fang, MD, MPH, FHM, associate professor and clinician-investigator in the department of medicine at University of California San Francisco (UCSF) Medical Center and a member of the SHM Research Committee. Critical to research success, they agree, is acquiring skills in research methodology and project design, finding the right mentor(s) to help guide your career, and committing to and preserving time to focus on your research.
“After residency,” Dr. Arora notes, “you have accumulated the clinical skills to become a hospitalist, but you usually have not accumulated the skill it takes to be a researcher, which is why you need to do additional training.”
Is a Fellowship Necessary?
The paths to incorporating research into one’s HM career can be diverse. Although a fellowship is often the recommended route, there are other ways to acquire research methodology and experience with project design. Dr. Leykum began her career as a clinician-educator at Columbia University in New York. Although she found the QI work enjoyable, she realized she wanted to understand how to create more meaningful and sustainable changes in inpatient care delivery. She later acquired a master’s degree in clinical investigation. She has published more than 25 journal articles, several in collaboration with other SHM colleagues.
As a result, perhaps, of her own experience—and the fact that HM is still a young subspecialty with limited HM-specific fellowship opportunities—Dr. Leykum says that she would consider hiring a junior faculty member who had not yet completed a fellowship. “I think you have to consider people who might be talented candidates that you are willing to groom,” she says. However, she says she would structure the position so that the faculty member could immediately pursue additional research training.
–Dr. Fang
Dr. Fang completed a two-year, general medical research fellowship right after her residency and obtained her master of public health degree at that time. “I do agree,” she says, “that the fastest way to doing research well is to get some additional training.”
Even if you are not aiming to become a full-time investigator, Dr. Arora says a research fellowship “gives you very marketable skills. You will still gain skills that will be helpful to your career—and not all research is done by clinician investigators in academic settings.”
Another advantage of a fellowship, Dr. Arora says, is that it allows you to explore whether you are truly suited for a research career. All three hospitalists agreed that researchers share many of the same abilities: to focus, accept uncertainty, persevere, work in teams, and handle rejection.
The Right Mentorship
Dr. Fang says working with an experienced mentor is a vital ingredient to launching a research career. One key factor in selecting a fellowship program, according to Dr. Leykum, is the institution’s or group’s track record in developing junior faculty. To gain an understanding of how the partnership would work on a practical level, the candidate should ask specific questions of prospective mentors, such as:
- How well do research interests and methodological expertise match?
- How often would we meet?
- Who would be involved in the mentorship team?
- What would each person contribute?
In hospital medicine, it could be challenging to find a mentor within one’s own division. Dr. Fang points out that there are a variety of other ways to obtain career, academic, and research mentorship: For example, SHM’s Research Committee has a fledgling mentoring program, and the Society of General Internal Medicine offers both one-on-one and longitudinal year-long mentoring. “You can also look to other specialty divisions that are complementary,” she suggests. If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.
Balance Clinical, Research Time
Although securing protected research time concerns trainees as well as academic faculty (see “Protect, Make the Most of Your Time,”), deleting clinical time from the equation is not the answer.
“I find, from being a researcher,” says Dr. Arora, “that sometimes you need a break from research. And clinical work can provide that break. Whatever you do, you need a balance.”
Dr. Leykum says she learned, about five years ago, that 10 weeks of clinical rotation was too little. By choice, she elects to put in more clinical time. Why? “Being in that [clinical] environment helps you hone your questions, especially if they concern how to better deliver care,” she says. “In addition, you interact with specialists and learn about the new research that they are implementing.”
The cross-feed between clinical and research pursuits can be particularly rich, Dr. Fang says. In addition to her other posts at UCSF, she is medical director of the anticoagulation clinic.
“I find a lot of my research ideas flow very naturally out of the situations I see as a hospitalist,” she says. “You often see something that you want to improve and design a project to try and achieve those aims.”
Gretchen Henkel is a freelance writer in southern California.
Protect, Make the Most of Your Time
Transitioning from a research fellowship to your first job, you will be negotiating for protected research time. A typical junior faculty position might involve 70% research time and 30% clinical time, says Dr. Arora, who cautions candidates to clarify how the 30% clinical time will be structured. “In a hospitalist group, 30% clinical time can look quite different and have varying amounts of nights and undesirable shifts.” It is appropriate, she noted, to ask this question, because this may have implications for your research time.
Candidates also need clarity from prospective institutions about funding expectations. Be prepared to secure your own funding as soon as possible. “You need to always look ahead,” says Dr. Arora, who suggests that young investigators view their first job as a “mini-grant” and use their time during that period to develop other funding sources, such as the NIH K, or career development, awards. —GH
References
- Leykum LK, Parekh VI, Sharpe B, Boonyasai RT, Centor RM. Tried and true: a survey of successfully promoted academic hospitalists. J Hosp Med. 2011;6(7):411-415.
- McKenna K, Leykum LK, McDaniel RR. The role of improvising in patient care. Health Care Manage Rev. 2013;38(1):1-8.
- Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642-1648.
- Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153.
- Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4): 395-401.
- Mission JF, Kerlan RK, Tan JH, Fang MC. Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients. J Gen Intern Med. 2010;25(4):321-325.
Are you attracted to research but not sure if it’s your sole calling as a prospective hospitalist? Whether you think you might want to steer quality improvement (QI) studies in the community setting or veer toward an academic/research career, hospital medicine offers an array of paths to career satisfaction.
“There is so much room in hospital medicine to find your research niche,” says Luci K. Leykum, MD, MBA, MSc, SFHM, hospital medicine division chief and associate dean for clinical affairs at University of Texas Health Science Center in San Antonio. As chair of SHM’s Research Committee, Dr. Leykum can attest to the range of hospitalists’ research pursuits: from basic science (what biomarkers best predict poor outcomes in patients with acute lung injury?) to care organization (are hospitalist schedules and workload associated with patient outcomes?) to implementation (how do we most effectively implement best practices for care transitions?) studies.1-6
In addition to Dr. Leykum, The Hospitalist consulted Vineet Arora, MD, MPP, FACP, SFHM, associate professor of medicine at the University of Chicago and chair of SHM’s Physicians in Training Committee, and Margaret Fang, MD, MPH, FHM, associate professor and clinician-investigator in the department of medicine at University of California San Francisco (UCSF) Medical Center and a member of the SHM Research Committee. Critical to research success, they agree, is acquiring skills in research methodology and project design, finding the right mentor(s) to help guide your career, and committing to and preserving time to focus on your research.
“After residency,” Dr. Arora notes, “you have accumulated the clinical skills to become a hospitalist, but you usually have not accumulated the skill it takes to be a researcher, which is why you need to do additional training.”
Is a Fellowship Necessary?
The paths to incorporating research into one’s HM career can be diverse. Although a fellowship is often the recommended route, there are other ways to acquire research methodology and experience with project design. Dr. Leykum began her career as a clinician-educator at Columbia University in New York. Although she found the QI work enjoyable, she realized she wanted to understand how to create more meaningful and sustainable changes in inpatient care delivery. She later acquired a master’s degree in clinical investigation. She has published more than 25 journal articles, several in collaboration with other SHM colleagues.
As a result, perhaps, of her own experience—and the fact that HM is still a young subspecialty with limited HM-specific fellowship opportunities—Dr. Leykum says that she would consider hiring a junior faculty member who had not yet completed a fellowship. “I think you have to consider people who might be talented candidates that you are willing to groom,” she says. However, she says she would structure the position so that the faculty member could immediately pursue additional research training.
–Dr. Fang
Dr. Fang completed a two-year, general medical research fellowship right after her residency and obtained her master of public health degree at that time. “I do agree,” she says, “that the fastest way to doing research well is to get some additional training.”
Even if you are not aiming to become a full-time investigator, Dr. Arora says a research fellowship “gives you very marketable skills. You will still gain skills that will be helpful to your career—and not all research is done by clinician investigators in academic settings.”
Another advantage of a fellowship, Dr. Arora says, is that it allows you to explore whether you are truly suited for a research career. All three hospitalists agreed that researchers share many of the same abilities: to focus, accept uncertainty, persevere, work in teams, and handle rejection.
The Right Mentorship
Dr. Fang says working with an experienced mentor is a vital ingredient to launching a research career. One key factor in selecting a fellowship program, according to Dr. Leykum, is the institution’s or group’s track record in developing junior faculty. To gain an understanding of how the partnership would work on a practical level, the candidate should ask specific questions of prospective mentors, such as:
- How well do research interests and methodological expertise match?
- How often would we meet?
- Who would be involved in the mentorship team?
- What would each person contribute?
In hospital medicine, it could be challenging to find a mentor within one’s own division. Dr. Fang points out that there are a variety of other ways to obtain career, academic, and research mentorship: For example, SHM’s Research Committee has a fledgling mentoring program, and the Society of General Internal Medicine offers both one-on-one and longitudinal year-long mentoring. “You can also look to other specialty divisions that are complementary,” she suggests. If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.
Balance Clinical, Research Time
Although securing protected research time concerns trainees as well as academic faculty (see “Protect, Make the Most of Your Time,”), deleting clinical time from the equation is not the answer.
“I find, from being a researcher,” says Dr. Arora, “that sometimes you need a break from research. And clinical work can provide that break. Whatever you do, you need a balance.”
Dr. Leykum says she learned, about five years ago, that 10 weeks of clinical rotation was too little. By choice, she elects to put in more clinical time. Why? “Being in that [clinical] environment helps you hone your questions, especially if they concern how to better deliver care,” she says. “In addition, you interact with specialists and learn about the new research that they are implementing.”
The cross-feed between clinical and research pursuits can be particularly rich, Dr. Fang says. In addition to her other posts at UCSF, she is medical director of the anticoagulation clinic.
“I find a lot of my research ideas flow very naturally out of the situations I see as a hospitalist,” she says. “You often see something that you want to improve and design a project to try and achieve those aims.”
Gretchen Henkel is a freelance writer in southern California.
Protect, Make the Most of Your Time
Transitioning from a research fellowship to your first job, you will be negotiating for protected research time. A typical junior faculty position might involve 70% research time and 30% clinical time, says Dr. Arora, who cautions candidates to clarify how the 30% clinical time will be structured. “In a hospitalist group, 30% clinical time can look quite different and have varying amounts of nights and undesirable shifts.” It is appropriate, she noted, to ask this question, because this may have implications for your research time.
Candidates also need clarity from prospective institutions about funding expectations. Be prepared to secure your own funding as soon as possible. “You need to always look ahead,” says Dr. Arora, who suggests that young investigators view their first job as a “mini-grant” and use their time during that period to develop other funding sources, such as the NIH K, or career development, awards. —GH
References
- Leykum LK, Parekh VI, Sharpe B, Boonyasai RT, Centor RM. Tried and true: a survey of successfully promoted academic hospitalists. J Hosp Med. 2011;6(7):411-415.
- McKenna K, Leykum LK, McDaniel RR. The role of improvising in patient care. Health Care Manage Rev. 2013;38(1):1-8.
- Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642-1648.
- Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153.
- Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4): 395-401.
- Mission JF, Kerlan RK, Tan JH, Fang MC. Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients. J Gen Intern Med. 2010;25(4):321-325.
Are you attracted to research but not sure if it’s your sole calling as a prospective hospitalist? Whether you think you might want to steer quality improvement (QI) studies in the community setting or veer toward an academic/research career, hospital medicine offers an array of paths to career satisfaction.
“There is so much room in hospital medicine to find your research niche,” says Luci K. Leykum, MD, MBA, MSc, SFHM, hospital medicine division chief and associate dean for clinical affairs at University of Texas Health Science Center in San Antonio. As chair of SHM’s Research Committee, Dr. Leykum can attest to the range of hospitalists’ research pursuits: from basic science (what biomarkers best predict poor outcomes in patients with acute lung injury?) to care organization (are hospitalist schedules and workload associated with patient outcomes?) to implementation (how do we most effectively implement best practices for care transitions?) studies.1-6
In addition to Dr. Leykum, The Hospitalist consulted Vineet Arora, MD, MPP, FACP, SFHM, associate professor of medicine at the University of Chicago and chair of SHM’s Physicians in Training Committee, and Margaret Fang, MD, MPH, FHM, associate professor and clinician-investigator in the department of medicine at University of California San Francisco (UCSF) Medical Center and a member of the SHM Research Committee. Critical to research success, they agree, is acquiring skills in research methodology and project design, finding the right mentor(s) to help guide your career, and committing to and preserving time to focus on your research.
“After residency,” Dr. Arora notes, “you have accumulated the clinical skills to become a hospitalist, but you usually have not accumulated the skill it takes to be a researcher, which is why you need to do additional training.”
Is a Fellowship Necessary?
The paths to incorporating research into one’s HM career can be diverse. Although a fellowship is often the recommended route, there are other ways to acquire research methodology and experience with project design. Dr. Leykum began her career as a clinician-educator at Columbia University in New York. Although she found the QI work enjoyable, she realized she wanted to understand how to create more meaningful and sustainable changes in inpatient care delivery. She later acquired a master’s degree in clinical investigation. She has published more than 25 journal articles, several in collaboration with other SHM colleagues.
As a result, perhaps, of her own experience—and the fact that HM is still a young subspecialty with limited HM-specific fellowship opportunities—Dr. Leykum says that she would consider hiring a junior faculty member who had not yet completed a fellowship. “I think you have to consider people who might be talented candidates that you are willing to groom,” she says. However, she says she would structure the position so that the faculty member could immediately pursue additional research training.
–Dr. Fang
Dr. Fang completed a two-year, general medical research fellowship right after her residency and obtained her master of public health degree at that time. “I do agree,” she says, “that the fastest way to doing research well is to get some additional training.”
Even if you are not aiming to become a full-time investigator, Dr. Arora says a research fellowship “gives you very marketable skills. You will still gain skills that will be helpful to your career—and not all research is done by clinician investigators in academic settings.”
Another advantage of a fellowship, Dr. Arora says, is that it allows you to explore whether you are truly suited for a research career. All three hospitalists agreed that researchers share many of the same abilities: to focus, accept uncertainty, persevere, work in teams, and handle rejection.
The Right Mentorship
Dr. Fang says working with an experienced mentor is a vital ingredient to launching a research career. One key factor in selecting a fellowship program, according to Dr. Leykum, is the institution’s or group’s track record in developing junior faculty. To gain an understanding of how the partnership would work on a practical level, the candidate should ask specific questions of prospective mentors, such as:
- How well do research interests and methodological expertise match?
- How often would we meet?
- Who would be involved in the mentorship team?
- What would each person contribute?
In hospital medicine, it could be challenging to find a mentor within one’s own division. Dr. Fang points out that there are a variety of other ways to obtain career, academic, and research mentorship: For example, SHM’s Research Committee has a fledgling mentoring program, and the Society of General Internal Medicine offers both one-on-one and longitudinal year-long mentoring. “You can also look to other specialty divisions that are complementary,” she suggests. If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.
Balance Clinical, Research Time
Although securing protected research time concerns trainees as well as academic faculty (see “Protect, Make the Most of Your Time,”), deleting clinical time from the equation is not the answer.
“I find, from being a researcher,” says Dr. Arora, “that sometimes you need a break from research. And clinical work can provide that break. Whatever you do, you need a balance.”
Dr. Leykum says she learned, about five years ago, that 10 weeks of clinical rotation was too little. By choice, she elects to put in more clinical time. Why? “Being in that [clinical] environment helps you hone your questions, especially if they concern how to better deliver care,” she says. “In addition, you interact with specialists and learn about the new research that they are implementing.”
The cross-feed between clinical and research pursuits can be particularly rich, Dr. Fang says. In addition to her other posts at UCSF, she is medical director of the anticoagulation clinic.
“I find a lot of my research ideas flow very naturally out of the situations I see as a hospitalist,” she says. “You often see something that you want to improve and design a project to try and achieve those aims.”
Gretchen Henkel is a freelance writer in southern California.
Protect, Make the Most of Your Time
Transitioning from a research fellowship to your first job, you will be negotiating for protected research time. A typical junior faculty position might involve 70% research time and 30% clinical time, says Dr. Arora, who cautions candidates to clarify how the 30% clinical time will be structured. “In a hospitalist group, 30% clinical time can look quite different and have varying amounts of nights and undesirable shifts.” It is appropriate, she noted, to ask this question, because this may have implications for your research time.
Candidates also need clarity from prospective institutions about funding expectations. Be prepared to secure your own funding as soon as possible. “You need to always look ahead,” says Dr. Arora, who suggests that young investigators view their first job as a “mini-grant” and use their time during that period to develop other funding sources, such as the NIH K, or career development, awards. —GH
References
- Leykum LK, Parekh VI, Sharpe B, Boonyasai RT, Centor RM. Tried and true: a survey of successfully promoted academic hospitalists. J Hosp Med. 2011;6(7):411-415.
- McKenna K, Leykum LK, McDaniel RR. The role of improvising in patient care. Health Care Manage Rev. 2013;38(1):1-8.
- Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642-1648.
- Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153.
- Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4): 395-401.
- Mission JF, Kerlan RK, Tan JH, Fang MC. Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients. J Gen Intern Med. 2010;25(4):321-325.
Hospital Medicine Blends Academic and Clinical Pursuits to Create Optimal Career Path
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Hospital Medicine’s Work-Life Balance Keeps Midori Larrabee Grounded
When she isn’t attending to patients or grappling with the latest update to electronic health records (EHR), Midori Larrabee, MD, is getting her hands dirty.
Literally.
Dr. Larrabee, a former hospitalist medical director at the 30-bed Valley General Hospital in Monroe, Wash., and her husband live on 2.5 acres of “paradise” outside of Seattle. They grow their own vegetables and recently planted an orchard. “We hope to get chickens next year,” she says.
“I love cooking and spending time with my husband, enjoying our little paradise,” says Dr. Larrabee, now working full-time as a hospitalist at 349-bed Overlake Medical Center in Bellevue, Wash. “I think being a hospitalist will only be sustainable if I have time away from the hospital to think about non-medical issues—like what worm is eating my radishes.”
Leisure-time passions aside, Dr. Larrabee chose HM for many of the same reasons hospitalists around the country do: “a variety of patients, the acuity of care, and the flexibility of the schedule. With half of the month off, I have time for activities other than clinical medicine.”
She considers herself a problem solver, using both sides of the brain to care for patients, mitigate staff schedules, and contribute to quality improvement projects.
“Initially, I was attracted to medicine due to my interest in biochemistry and the physiology of how we function,” says Dr. Larrabee, one of nine new members of Team Hospitalist, the volunteer, editorial advisory group for The Hospitalist. “As I’ve grown up, I started to see the value in being a part of patients/families’ lives during an event like a hospitalization. I can use my knowledge to help guide them, educate them, and, hopefully, reassure them during a time when they may feel helpless.”
Question: How did you decide to become a hospitalist?
Answer: I decided to become a hospitalist during residency. Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases. Also, I liked dealing with sicker patients where more acute decisions had to be made and the results were quickly evident.
Q: Outside of patient care, tell me about your career interests?
A: I am on the P&T committee at (Overlake), and work as part of a team developing projects to improve patient satisfaction during their hospitalization. During the summers I perform evaluations of local medic students at the end of their training program (done through the Seattle Fire Department). I have previously been on the Medical Executive Committee at my smaller hospital and really enjoyed those activities. I would like to be more involved in quality projects at my hospital and hopefully will find some opportunities in the next year.
–Dr. Larrabee
Q: What’s the best advice you ever received?
A: Make yourself happy. If you keep coming back to the question “Am I happy?” you can always have a way to center yourself. If you say “Yes,” then you can feel good about where you are in life, even if that wasn’t what you were expecting or planning. If you say “No,” then at least you now know that something needs to change.
Q: What’s the one thing you most dislike about your job?
A: The time spent with the electronic health record. I am spending more time figuring out how to order a therapy, write a note, or sign an order than actually at the bedside interacting with the patient.
Q: What is your biggest professional challenge?
A: My lack of patience. I want to be in more leadership positions, be a respected physician at my hospital, and have a greater role in the community NOW. I have only worked at my larger hospital for about a year, and I know it takes time to get to know everyone, get to know the culture of the hospital, and work my way up the ranks.
Q: What is your biggest professional reward?
A: I love when I really connect with a patient or family and feel like I’ve made a difference. As a hospitalist, it sometimes feels like I am admitting patients with chronic medical problems that will never get better, get them just well enough to leave the hospital, but never really make a difference. When you can really connect, that is always a great reward. An example is an elderly patient I cared for recently. He was clearly dying, but the family was having a hard time accepting his course. I spent time with the family and helped them reconcile their hopes to keep him comfortable with their fears about killing the patriarch of the family. They eventually transitioned the patient to hospice care, and although he did pass away, I feel like I was able to make the patient’s death a little better for the family and for him.
Q: Where do you see yourself in 10 years?
A: I always see myself working clinically for at least part of my time. Medicine would get too boring if it wasn’t for the patients. That said, I like a variety of activities and stay motivated when something new is on the horizon. I don’t know if a climb up the ladder is in my future, but if things work out that way, I would be open to the chance. Otherwise, I try and keep my eyes out for new challenges. If I try and plan my path out too much, I will miss those great, unexpected opportunities.
Q: What’s the best book you’ve read recently?
A: “Vegetable Literacy” by Deborah Madison. I love to cook and garden, and this book describes the different edible members of botanical families—and then gives recipes. The book motivates you to try new varieties in the garden and kitchen. The beautiful pictures didn’t hurt, either. Pictures always make a book better.
Q: How many Apple products do you interface with in a given week?
A: One, my iPhone. AppleTV never works right, so we stopped trying to use that months ago.
Richard Quinn is a freelance writer in New Jersey.
When she isn’t attending to patients or grappling with the latest update to electronic health records (EHR), Midori Larrabee, MD, is getting her hands dirty.
Literally.
Dr. Larrabee, a former hospitalist medical director at the 30-bed Valley General Hospital in Monroe, Wash., and her husband live on 2.5 acres of “paradise” outside of Seattle. They grow their own vegetables and recently planted an orchard. “We hope to get chickens next year,” she says.
“I love cooking and spending time with my husband, enjoying our little paradise,” says Dr. Larrabee, now working full-time as a hospitalist at 349-bed Overlake Medical Center in Bellevue, Wash. “I think being a hospitalist will only be sustainable if I have time away from the hospital to think about non-medical issues—like what worm is eating my radishes.”
Leisure-time passions aside, Dr. Larrabee chose HM for many of the same reasons hospitalists around the country do: “a variety of patients, the acuity of care, and the flexibility of the schedule. With half of the month off, I have time for activities other than clinical medicine.”
She considers herself a problem solver, using both sides of the brain to care for patients, mitigate staff schedules, and contribute to quality improvement projects.
“Initially, I was attracted to medicine due to my interest in biochemistry and the physiology of how we function,” says Dr. Larrabee, one of nine new members of Team Hospitalist, the volunteer, editorial advisory group for The Hospitalist. “As I’ve grown up, I started to see the value in being a part of patients/families’ lives during an event like a hospitalization. I can use my knowledge to help guide them, educate them, and, hopefully, reassure them during a time when they may feel helpless.”
Question: How did you decide to become a hospitalist?
Answer: I decided to become a hospitalist during residency. Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases. Also, I liked dealing with sicker patients where more acute decisions had to be made and the results were quickly evident.
Q: Outside of patient care, tell me about your career interests?
A: I am on the P&T committee at (Overlake), and work as part of a team developing projects to improve patient satisfaction during their hospitalization. During the summers I perform evaluations of local medic students at the end of their training program (done through the Seattle Fire Department). I have previously been on the Medical Executive Committee at my smaller hospital and really enjoyed those activities. I would like to be more involved in quality projects at my hospital and hopefully will find some opportunities in the next year.
–Dr. Larrabee
Q: What’s the best advice you ever received?
A: Make yourself happy. If you keep coming back to the question “Am I happy?” you can always have a way to center yourself. If you say “Yes,” then you can feel good about where you are in life, even if that wasn’t what you were expecting or planning. If you say “No,” then at least you now know that something needs to change.
Q: What’s the one thing you most dislike about your job?
A: The time spent with the electronic health record. I am spending more time figuring out how to order a therapy, write a note, or sign an order than actually at the bedside interacting with the patient.
Q: What is your biggest professional challenge?
A: My lack of patience. I want to be in more leadership positions, be a respected physician at my hospital, and have a greater role in the community NOW. I have only worked at my larger hospital for about a year, and I know it takes time to get to know everyone, get to know the culture of the hospital, and work my way up the ranks.
Q: What is your biggest professional reward?
A: I love when I really connect with a patient or family and feel like I’ve made a difference. As a hospitalist, it sometimes feels like I am admitting patients with chronic medical problems that will never get better, get them just well enough to leave the hospital, but never really make a difference. When you can really connect, that is always a great reward. An example is an elderly patient I cared for recently. He was clearly dying, but the family was having a hard time accepting his course. I spent time with the family and helped them reconcile their hopes to keep him comfortable with their fears about killing the patriarch of the family. They eventually transitioned the patient to hospice care, and although he did pass away, I feel like I was able to make the patient’s death a little better for the family and for him.
Q: Where do you see yourself in 10 years?
A: I always see myself working clinically for at least part of my time. Medicine would get too boring if it wasn’t for the patients. That said, I like a variety of activities and stay motivated when something new is on the horizon. I don’t know if a climb up the ladder is in my future, but if things work out that way, I would be open to the chance. Otherwise, I try and keep my eyes out for new challenges. If I try and plan my path out too much, I will miss those great, unexpected opportunities.
Q: What’s the best book you’ve read recently?
A: “Vegetable Literacy” by Deborah Madison. I love to cook and garden, and this book describes the different edible members of botanical families—and then gives recipes. The book motivates you to try new varieties in the garden and kitchen. The beautiful pictures didn’t hurt, either. Pictures always make a book better.
Q: How many Apple products do you interface with in a given week?
A: One, my iPhone. AppleTV never works right, so we stopped trying to use that months ago.
Richard Quinn is a freelance writer in New Jersey.
When she isn’t attending to patients or grappling with the latest update to electronic health records (EHR), Midori Larrabee, MD, is getting her hands dirty.
Literally.
Dr. Larrabee, a former hospitalist medical director at the 30-bed Valley General Hospital in Monroe, Wash., and her husband live on 2.5 acres of “paradise” outside of Seattle. They grow their own vegetables and recently planted an orchard. “We hope to get chickens next year,” she says.
“I love cooking and spending time with my husband, enjoying our little paradise,” says Dr. Larrabee, now working full-time as a hospitalist at 349-bed Overlake Medical Center in Bellevue, Wash. “I think being a hospitalist will only be sustainable if I have time away from the hospital to think about non-medical issues—like what worm is eating my radishes.”
Leisure-time passions aside, Dr. Larrabee chose HM for many of the same reasons hospitalists around the country do: “a variety of patients, the acuity of care, and the flexibility of the schedule. With half of the month off, I have time for activities other than clinical medicine.”
She considers herself a problem solver, using both sides of the brain to care for patients, mitigate staff schedules, and contribute to quality improvement projects.
“Initially, I was attracted to medicine due to my interest in biochemistry and the physiology of how we function,” says Dr. Larrabee, one of nine new members of Team Hospitalist, the volunteer, editorial advisory group for The Hospitalist. “As I’ve grown up, I started to see the value in being a part of patients/families’ lives during an event like a hospitalization. I can use my knowledge to help guide them, educate them, and, hopefully, reassure them during a time when they may feel helpless.”
Question: How did you decide to become a hospitalist?
Answer: I decided to become a hospitalist during residency. Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases. Also, I liked dealing with sicker patients where more acute decisions had to be made and the results were quickly evident.
Q: Outside of patient care, tell me about your career interests?
A: I am on the P&T committee at (Overlake), and work as part of a team developing projects to improve patient satisfaction during their hospitalization. During the summers I perform evaluations of local medic students at the end of their training program (done through the Seattle Fire Department). I have previously been on the Medical Executive Committee at my smaller hospital and really enjoyed those activities. I would like to be more involved in quality projects at my hospital and hopefully will find some opportunities in the next year.
–Dr. Larrabee
Q: What’s the best advice you ever received?
A: Make yourself happy. If you keep coming back to the question “Am I happy?” you can always have a way to center yourself. If you say “Yes,” then you can feel good about where you are in life, even if that wasn’t what you were expecting or planning. If you say “No,” then at least you now know that something needs to change.
Q: What’s the one thing you most dislike about your job?
A: The time spent with the electronic health record. I am spending more time figuring out how to order a therapy, write a note, or sign an order than actually at the bedside interacting with the patient.
Q: What is your biggest professional challenge?
A: My lack of patience. I want to be in more leadership positions, be a respected physician at my hospital, and have a greater role in the community NOW. I have only worked at my larger hospital for about a year, and I know it takes time to get to know everyone, get to know the culture of the hospital, and work my way up the ranks.
Q: What is your biggest professional reward?
A: I love when I really connect with a patient or family and feel like I’ve made a difference. As a hospitalist, it sometimes feels like I am admitting patients with chronic medical problems that will never get better, get them just well enough to leave the hospital, but never really make a difference. When you can really connect, that is always a great reward. An example is an elderly patient I cared for recently. He was clearly dying, but the family was having a hard time accepting his course. I spent time with the family and helped them reconcile their hopes to keep him comfortable with their fears about killing the patriarch of the family. They eventually transitioned the patient to hospice care, and although he did pass away, I feel like I was able to make the patient’s death a little better for the family and for him.
Q: Where do you see yourself in 10 years?
A: I always see myself working clinically for at least part of my time. Medicine would get too boring if it wasn’t for the patients. That said, I like a variety of activities and stay motivated when something new is on the horizon. I don’t know if a climb up the ladder is in my future, but if things work out that way, I would be open to the chance. Otherwise, I try and keep my eyes out for new challenges. If I try and plan my path out too much, I will miss those great, unexpected opportunities.
Q: What’s the best book you’ve read recently?
A: “Vegetable Literacy” by Deborah Madison. I love to cook and garden, and this book describes the different edible members of botanical families—and then gives recipes. The book motivates you to try new varieties in the garden and kitchen. The beautiful pictures didn’t hurt, either. Pictures always make a book better.
Q: How many Apple products do you interface with in a given week?
A: One, my iPhone. AppleTV never works right, so we stopped trying to use that months ago.
Richard Quinn is a freelance writer in New Jersey.
University of Chicago Hospitalist Scholars Program Wins Award
Under the leadership of David Meltzer, MD, PhD, MHM, the University of Chicago Hospitalist Scholars Program is one of 13 organizations to earn the prestigious Association of American Medical Colleges’ Learning Health System Challenge and Planning Awards.
The program provides training in research, medical education, and quality improvement to help young physicians develop into successful academic hospitalists who can become leaders in these domains. Required resources include mentorship and opportunities for formal didactic instruction for the scholars and a functioning clinical research environment.
The AAMC Learning Health System Challenge and Planning Awards recognize innovations in medical education, care delivery, research, and diversity and inclusion.
Under the leadership of David Meltzer, MD, PhD, MHM, the University of Chicago Hospitalist Scholars Program is one of 13 organizations to earn the prestigious Association of American Medical Colleges’ Learning Health System Challenge and Planning Awards.
The program provides training in research, medical education, and quality improvement to help young physicians develop into successful academic hospitalists who can become leaders in these domains. Required resources include mentorship and opportunities for formal didactic instruction for the scholars and a functioning clinical research environment.
The AAMC Learning Health System Challenge and Planning Awards recognize innovations in medical education, care delivery, research, and diversity and inclusion.
Under the leadership of David Meltzer, MD, PhD, MHM, the University of Chicago Hospitalist Scholars Program is one of 13 organizations to earn the prestigious Association of American Medical Colleges’ Learning Health System Challenge and Planning Awards.
The program provides training in research, medical education, and quality improvement to help young physicians develop into successful academic hospitalists who can become leaders in these domains. Required resources include mentorship and opportunities for formal didactic instruction for the scholars and a functioning clinical research environment.
The AAMC Learning Health System Challenge and Planning Awards recognize innovations in medical education, care delivery, research, and diversity and inclusion.
Physician Value-Based Payment Modifier To Make Changes for Hospitalists
“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.
For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.
The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.
At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.
SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.
At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.
Joshua Lapps is SHM’s government relations specialist.
“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.
For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.
The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.
At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.
SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.
At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.
Joshua Lapps is SHM’s government relations specialist.
“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.
For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.
The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.
At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.
SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.
At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.
Joshua Lapps is SHM’s government relations specialist.
HM14 At Hand Mobile App Enhanced Functionality Helps Hospitalists Plan For Annual Meeting
With its added functionality, the HM14 at Hand app is likely to be even more popular. This year, the HM14 at Hand includes:
- Full program schedule, with the ability to schedule and set reminders for selected sessions;
- Options for presenters and conference-goers to provide contact information to other attendees;
- Presentation notes from speakers;
- The “Scan-to-Win” game, with even more locations to scan in 2014;
- Real-time program alerts for breaking news about the conference;
- Links to other resources for hospitalists;
- NEW: Integration with social media to help you connect with other conference bloggers, tweeters, and posters; and
- NEW: A section for job seekers and career networkers to connect with recruiters.
But don’t wait until you get to the meeting to download the app. HM14 at Hand helps hospitalists plan for the meeting ahead of time by highlighting and saving sessions to attend, lists contact information for other attendees who’ve opted to network via the app, and provides conference updates before and during the meeting.
With its added functionality, the HM14 at Hand app is likely to be even more popular. This year, the HM14 at Hand includes:
- Full program schedule, with the ability to schedule and set reminders for selected sessions;
- Options for presenters and conference-goers to provide contact information to other attendees;
- Presentation notes from speakers;
- The “Scan-to-Win” game, with even more locations to scan in 2014;
- Real-time program alerts for breaking news about the conference;
- Links to other resources for hospitalists;
- NEW: Integration with social media to help you connect with other conference bloggers, tweeters, and posters; and
- NEW: A section for job seekers and career networkers to connect with recruiters.
But don’t wait until you get to the meeting to download the app. HM14 at Hand helps hospitalists plan for the meeting ahead of time by highlighting and saving sessions to attend, lists contact information for other attendees who’ve opted to network via the app, and provides conference updates before and during the meeting.
With its added functionality, the HM14 at Hand app is likely to be even more popular. This year, the HM14 at Hand includes:
- Full program schedule, with the ability to schedule and set reminders for selected sessions;
- Options for presenters and conference-goers to provide contact information to other attendees;
- Presentation notes from speakers;
- The “Scan-to-Win” game, with even more locations to scan in 2014;
- Real-time program alerts for breaking news about the conference;
- Links to other resources for hospitalists;
- NEW: Integration with social media to help you connect with other conference bloggers, tweeters, and posters; and
- NEW: A section for job seekers and career networkers to connect with recruiters.
But don’t wait until you get to the meeting to download the app. HM14 at Hand helps hospitalists plan for the meeting ahead of time by highlighting and saving sessions to attend, lists contact information for other attendees who’ve opted to network via the app, and provides conference updates before and during the meeting.
Movers and Shakers in Hospital Medicine
HM MOVERS AND SHAKERS
Business Moves
Sound Physicians, based in Tacoma, Wash., is now providing hospitalist services at both Christus Santa Rosa Health System in San Antonio, Texas, and John Peter Smith Hospital in Fort Worth, Texas. Christus Santa Rosa consists of four acute care hospitals, the Children’s Hospital of San Antonio, and several outpatient clinics and emergency centers in the greater San Antonio area. John Peter Smith Hospital is a 537-bed trauma center serving the central Fort Worth area.
IPC The Hospitalist Company, based in North Hollywood, Calif., has acquired the practice groups of Bruce G. Johnson, DO, PC, in Roseville, Mich.; Allen Trager, DO, PC, in Flint, Mich.; and Victor Toledano, MD, PA, in Ft. Lauderdale, Fla. IPC also completed its acquisition of Park Avenue Health Care Management, LLC; Park Avenue Medical Associates, PC; Park Avenue Medical Associates, LLC; and Geriatric Services, PC, (collectively, “Park Avenue”), all based in White Plains, N.Y. IPC now provides hospitalist services in 28 states.
Heart of Lancaster Regional Medical Center in Lititz, Pa., is now providing pediatric hospitalist services. Initially, the program will staff six pediatric hospitalists at the 148-bed facility. The facility joins Lancaster General Hospital as the second in the county to provide pediatric hospital medicine services.
Morthland College Health Services (MCHS) in West Frankfort, Ill., has assumed coverage of hospitalist services at Harrisburg Medical Center (HMC) in Harrisburg, Ill. MCHS already provides hospital medicine services at Franklin Hospital in Benton, Ill. Morthland College is a small liberal arts college founded in 2009. Harrisburg Medical Center is a 98-bed acute care hospital serving greater Saline County, Ill.
The Ob Hospitalist Group (OBHG), based in Mauldin, S.C., is providing services to Bayhealth Milford Memorial Hospital in Milford, Del. Milford Memorial has served communities in the Milford area since 1938. OBHG provides inpatient OB/GYN services to nearly 50 hospitals and clinics nationwide.
St. Alexius Medical Center in Bismarck, N.D., has partnered with the University of North Dakota to institute a new hospitalist fellowship program in North Dakota. The one-year program is the first of its kind in North Dakota.
HM MOVERS AND SHAKERS
Business Moves
Sound Physicians, based in Tacoma, Wash., is now providing hospitalist services at both Christus Santa Rosa Health System in San Antonio, Texas, and John Peter Smith Hospital in Fort Worth, Texas. Christus Santa Rosa consists of four acute care hospitals, the Children’s Hospital of San Antonio, and several outpatient clinics and emergency centers in the greater San Antonio area. John Peter Smith Hospital is a 537-bed trauma center serving the central Fort Worth area.
IPC The Hospitalist Company, based in North Hollywood, Calif., has acquired the practice groups of Bruce G. Johnson, DO, PC, in Roseville, Mich.; Allen Trager, DO, PC, in Flint, Mich.; and Victor Toledano, MD, PA, in Ft. Lauderdale, Fla. IPC also completed its acquisition of Park Avenue Health Care Management, LLC; Park Avenue Medical Associates, PC; Park Avenue Medical Associates, LLC; and Geriatric Services, PC, (collectively, “Park Avenue”), all based in White Plains, N.Y. IPC now provides hospitalist services in 28 states.
Heart of Lancaster Regional Medical Center in Lititz, Pa., is now providing pediatric hospitalist services. Initially, the program will staff six pediatric hospitalists at the 148-bed facility. The facility joins Lancaster General Hospital as the second in the county to provide pediatric hospital medicine services.
Morthland College Health Services (MCHS) in West Frankfort, Ill., has assumed coverage of hospitalist services at Harrisburg Medical Center (HMC) in Harrisburg, Ill. MCHS already provides hospital medicine services at Franklin Hospital in Benton, Ill. Morthland College is a small liberal arts college founded in 2009. Harrisburg Medical Center is a 98-bed acute care hospital serving greater Saline County, Ill.
The Ob Hospitalist Group (OBHG), based in Mauldin, S.C., is providing services to Bayhealth Milford Memorial Hospital in Milford, Del. Milford Memorial has served communities in the Milford area since 1938. OBHG provides inpatient OB/GYN services to nearly 50 hospitals and clinics nationwide.
St. Alexius Medical Center in Bismarck, N.D., has partnered with the University of North Dakota to institute a new hospitalist fellowship program in North Dakota. The one-year program is the first of its kind in North Dakota.
HM MOVERS AND SHAKERS
Business Moves
Sound Physicians, based in Tacoma, Wash., is now providing hospitalist services at both Christus Santa Rosa Health System in San Antonio, Texas, and John Peter Smith Hospital in Fort Worth, Texas. Christus Santa Rosa consists of four acute care hospitals, the Children’s Hospital of San Antonio, and several outpatient clinics and emergency centers in the greater San Antonio area. John Peter Smith Hospital is a 537-bed trauma center serving the central Fort Worth area.
IPC The Hospitalist Company, based in North Hollywood, Calif., has acquired the practice groups of Bruce G. Johnson, DO, PC, in Roseville, Mich.; Allen Trager, DO, PC, in Flint, Mich.; and Victor Toledano, MD, PA, in Ft. Lauderdale, Fla. IPC also completed its acquisition of Park Avenue Health Care Management, LLC; Park Avenue Medical Associates, PC; Park Avenue Medical Associates, LLC; and Geriatric Services, PC, (collectively, “Park Avenue”), all based in White Plains, N.Y. IPC now provides hospitalist services in 28 states.
Heart of Lancaster Regional Medical Center in Lititz, Pa., is now providing pediatric hospitalist services. Initially, the program will staff six pediatric hospitalists at the 148-bed facility. The facility joins Lancaster General Hospital as the second in the county to provide pediatric hospital medicine services.
Morthland College Health Services (MCHS) in West Frankfort, Ill., has assumed coverage of hospitalist services at Harrisburg Medical Center (HMC) in Harrisburg, Ill. MCHS already provides hospital medicine services at Franklin Hospital in Benton, Ill. Morthland College is a small liberal arts college founded in 2009. Harrisburg Medical Center is a 98-bed acute care hospital serving greater Saline County, Ill.
The Ob Hospitalist Group (OBHG), based in Mauldin, S.C., is providing services to Bayhealth Milford Memorial Hospital in Milford, Del. Milford Memorial has served communities in the Milford area since 1938. OBHG provides inpatient OB/GYN services to nearly 50 hospitals and clinics nationwide.
St. Alexius Medical Center in Bismarck, N.D., has partnered with the University of North Dakota to institute a new hospitalist fellowship program in North Dakota. The one-year program is the first of its kind in North Dakota.
Society of Hospital Medicine’s Project BOOST Reduces Medicare Penalties and Readmissions
SHM’s Project BOOST is accepting applications for its 2014 cohort, giving hospitalists and hospital-based team members time to complete the application and receive buy-in from hospital executives to participate in the program.
And this year is the best year yet to make the case to hospital leadership for using Project BOOST to reduce hospital readmissions. More than 180 hospitals throughout the U.S. have used Project BOOST to systematically tackle readmissions.
Last year, the first peer-reviewed research on Project BOOST, published in the Journal of Hospital Medicine, showed that the program reduced 30-day readmissions to 12.7% from 14.7% among 11 hospitals participating in the study. In addition, media and government agencies taking a hard look at readmissions rates have also used Project BOOST as an example of programs that can reduce readmissions and avoid Medicare penalties.1
Accepted Project BOOST sites begin the yearlong program with an in-person training conference with other BOOST sites. After the training, participants utilize a comprehensive toolkit to begin implementing their own programs, followed by ongoing mentoring with national experts in reducing readmissions and collaboration with other hospitals tackling similar challenges.
Details, educational resources, and free on-demand webinars are available at www.hospitalmedicine.org/projectboost.
Brendon Shank is SHM’s associate vice president of communications.
Reference
SHM’s Project BOOST is accepting applications for its 2014 cohort, giving hospitalists and hospital-based team members time to complete the application and receive buy-in from hospital executives to participate in the program.
And this year is the best year yet to make the case to hospital leadership for using Project BOOST to reduce hospital readmissions. More than 180 hospitals throughout the U.S. have used Project BOOST to systematically tackle readmissions.
Last year, the first peer-reviewed research on Project BOOST, published in the Journal of Hospital Medicine, showed that the program reduced 30-day readmissions to 12.7% from 14.7% among 11 hospitals participating in the study. In addition, media and government agencies taking a hard look at readmissions rates have also used Project BOOST as an example of programs that can reduce readmissions and avoid Medicare penalties.1
Accepted Project BOOST sites begin the yearlong program with an in-person training conference with other BOOST sites. After the training, participants utilize a comprehensive toolkit to begin implementing their own programs, followed by ongoing mentoring with national experts in reducing readmissions and collaboration with other hospitals tackling similar challenges.
Details, educational resources, and free on-demand webinars are available at www.hospitalmedicine.org/projectboost.
Brendon Shank is SHM’s associate vice president of communications.
Reference
SHM’s Project BOOST is accepting applications for its 2014 cohort, giving hospitalists and hospital-based team members time to complete the application and receive buy-in from hospital executives to participate in the program.
And this year is the best year yet to make the case to hospital leadership for using Project BOOST to reduce hospital readmissions. More than 180 hospitals throughout the U.S. have used Project BOOST to systematically tackle readmissions.
Last year, the first peer-reviewed research on Project BOOST, published in the Journal of Hospital Medicine, showed that the program reduced 30-day readmissions to 12.7% from 14.7% among 11 hospitals participating in the study. In addition, media and government agencies taking a hard look at readmissions rates have also used Project BOOST as an example of programs that can reduce readmissions and avoid Medicare penalties.1
Accepted Project BOOST sites begin the yearlong program with an in-person training conference with other BOOST sites. After the training, participants utilize a comprehensive toolkit to begin implementing their own programs, followed by ongoing mentoring with national experts in reducing readmissions and collaboration with other hospitals tackling similar challenges.
Details, educational resources, and free on-demand webinars are available at www.hospitalmedicine.org/projectboost.
Brendon Shank is SHM’s associate vice president of communications.
Reference
Centers for Medicare & Medicaid Services Modify Physician Quality Reporting System
Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).
“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.
Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).
“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.
In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.
For Comparison’s Sake
For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.
Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.
If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.
New Brand, New Push
PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.
This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.
In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.
The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.
“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.
Moving Forward
In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).
Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.
“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”
Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.
Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.
“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.
Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.
“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”
Kelly April Tyrrell is a freelance writer in Wilmington, Del.
Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).
“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.
Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).
“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.
In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.
For Comparison’s Sake
For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.
Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.
If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.
New Brand, New Push
PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.
This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.
In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.
The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.
“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.
Moving Forward
In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).
Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.
“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”
Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.
Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.
“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.
Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.
“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”
Kelly April Tyrrell is a freelance writer in Wilmington, Del.
Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).
“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.
Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).
“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.
In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.
For Comparison’s Sake
For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.
Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.
If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.
New Brand, New Push
PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.
This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.
In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.
The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.
“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.
Moving Forward
In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).
Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.
“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”
Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.
Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.
“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.
Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.
“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”
Kelly April Tyrrell is a freelance writer in Wilmington, Del.
Aggregate Early Warning Score Results Mixed for High-Risk Pediatric Patients
Clinical question: Do rapid response systems (RRS) reduce the rate of critical deterioration (CD) in hospitalized children?
Background: Over the past decade, a majority of pediatric inpatient units and freestanding children’s hospitals have instituted RRSs that utilize medical emergency teams (MET) to rapidly evaluate clinically deteriorating patients. Pediatric RRSs manifest variability between institutions in MET composition and RRS triggers. Prior studies of RRSs in the pediatric population have been mixed, with a lack of robust evidence that RRSs reduce hospital mortality and cardiopulmonary arrest rates. Evaluation of the effect of RRSs in pediatric units and hospitals is complicated by the heterogeneity of pediatric RRS implementation and the overall low rate of in-hospital cardiopulmonary arrest and death. In a 2012 study, the authors defined CD events as those leading to ICU transfer and subsequent mechanical ventilation (noninvasive or invasive) or vasopressor infusion within 12 hours. CD event rates, quantified as an event rate per 1,000 non-ICU patient-days, were found to be associated with a >13-fold increase in risk of in-hospital death and were believed to be a valid proximate outcome for in-hospital mortality.
Study design: Single-center interrupted time series analysis
Setting: 516-bed urban, tertiary care, freestanding children’s hospital.
Synopsis: The RRS at this institution consisted of an aggregate early warning score (EWS), which triggered the response of a MET (within 30 minutes) 24 hours a day, seven days a week. Distinct from the code-blue team, the MET comprised PICU staff, including: (1) a fellow, attending, or nurse practitioner; (2) a nurse; and (3) a respiratory therapist. Researchers compared the 32 months prior to implementation to the 27 months after implementation. An interrupted time series analysis was performed using advanced statistical modeling with adjustments for season, ward, and case-mix index.
Although there were no significant differences in rates of cardiopulmonary arrest or mortality, adjusted analysis revealed a net 62% reduction in CD event rate (IRR=0.38) after initiation of the RRS. Adjusted analysis also found a net 83% reduction in mechanical ventilation events (IRR=0.17) and a net 80% reduction in vasopressor use (IRR=0.20). Of note, these reductions were not significant in the unadjusted analyses. After transfer to the ICU, time elapsed until initiation of either mechanical ventilation or vasopressor use was longer.
Bottom line: With an aggregate EWS identifying high-risk patients requiring rapid evaluation by a MET, a pediatric RRS reduces adjusted rates of CD events but might not yield significant reductions in unadjusted rates of mortality, cardiopulmonary arrest, or CD events.
Citation: Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system imple-mentation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33.
Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.
Clinical question: Do rapid response systems (RRS) reduce the rate of critical deterioration (CD) in hospitalized children?
Background: Over the past decade, a majority of pediatric inpatient units and freestanding children’s hospitals have instituted RRSs that utilize medical emergency teams (MET) to rapidly evaluate clinically deteriorating patients. Pediatric RRSs manifest variability between institutions in MET composition and RRS triggers. Prior studies of RRSs in the pediatric population have been mixed, with a lack of robust evidence that RRSs reduce hospital mortality and cardiopulmonary arrest rates. Evaluation of the effect of RRSs in pediatric units and hospitals is complicated by the heterogeneity of pediatric RRS implementation and the overall low rate of in-hospital cardiopulmonary arrest and death. In a 2012 study, the authors defined CD events as those leading to ICU transfer and subsequent mechanical ventilation (noninvasive or invasive) or vasopressor infusion within 12 hours. CD event rates, quantified as an event rate per 1,000 non-ICU patient-days, were found to be associated with a >13-fold increase in risk of in-hospital death and were believed to be a valid proximate outcome for in-hospital mortality.
Study design: Single-center interrupted time series analysis
Setting: 516-bed urban, tertiary care, freestanding children’s hospital.
Synopsis: The RRS at this institution consisted of an aggregate early warning score (EWS), which triggered the response of a MET (within 30 minutes) 24 hours a day, seven days a week. Distinct from the code-blue team, the MET comprised PICU staff, including: (1) a fellow, attending, or nurse practitioner; (2) a nurse; and (3) a respiratory therapist. Researchers compared the 32 months prior to implementation to the 27 months after implementation. An interrupted time series analysis was performed using advanced statistical modeling with adjustments for season, ward, and case-mix index.
Although there were no significant differences in rates of cardiopulmonary arrest or mortality, adjusted analysis revealed a net 62% reduction in CD event rate (IRR=0.38) after initiation of the RRS. Adjusted analysis also found a net 83% reduction in mechanical ventilation events (IRR=0.17) and a net 80% reduction in vasopressor use (IRR=0.20). Of note, these reductions were not significant in the unadjusted analyses. After transfer to the ICU, time elapsed until initiation of either mechanical ventilation or vasopressor use was longer.
Bottom line: With an aggregate EWS identifying high-risk patients requiring rapid evaluation by a MET, a pediatric RRS reduces adjusted rates of CD events but might not yield significant reductions in unadjusted rates of mortality, cardiopulmonary arrest, or CD events.
Citation: Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system imple-mentation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33.
Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.
Clinical question: Do rapid response systems (RRS) reduce the rate of critical deterioration (CD) in hospitalized children?
Background: Over the past decade, a majority of pediatric inpatient units and freestanding children’s hospitals have instituted RRSs that utilize medical emergency teams (MET) to rapidly evaluate clinically deteriorating patients. Pediatric RRSs manifest variability between institutions in MET composition and RRS triggers. Prior studies of RRSs in the pediatric population have been mixed, with a lack of robust evidence that RRSs reduce hospital mortality and cardiopulmonary arrest rates. Evaluation of the effect of RRSs in pediatric units and hospitals is complicated by the heterogeneity of pediatric RRS implementation and the overall low rate of in-hospital cardiopulmonary arrest and death. In a 2012 study, the authors defined CD events as those leading to ICU transfer and subsequent mechanical ventilation (noninvasive or invasive) or vasopressor infusion within 12 hours. CD event rates, quantified as an event rate per 1,000 non-ICU patient-days, were found to be associated with a >13-fold increase in risk of in-hospital death and were believed to be a valid proximate outcome for in-hospital mortality.
Study design: Single-center interrupted time series analysis
Setting: 516-bed urban, tertiary care, freestanding children’s hospital.
Synopsis: The RRS at this institution consisted of an aggregate early warning score (EWS), which triggered the response of a MET (within 30 minutes) 24 hours a day, seven days a week. Distinct from the code-blue team, the MET comprised PICU staff, including: (1) a fellow, attending, or nurse practitioner; (2) a nurse; and (3) a respiratory therapist. Researchers compared the 32 months prior to implementation to the 27 months after implementation. An interrupted time series analysis was performed using advanced statistical modeling with adjustments for season, ward, and case-mix index.
Although there were no significant differences in rates of cardiopulmonary arrest or mortality, adjusted analysis revealed a net 62% reduction in CD event rate (IRR=0.38) after initiation of the RRS. Adjusted analysis also found a net 83% reduction in mechanical ventilation events (IRR=0.17) and a net 80% reduction in vasopressor use (IRR=0.20). Of note, these reductions were not significant in the unadjusted analyses. After transfer to the ICU, time elapsed until initiation of either mechanical ventilation or vasopressor use was longer.
Bottom line: With an aggregate EWS identifying high-risk patients requiring rapid evaluation by a MET, a pediatric RRS reduces adjusted rates of CD events but might not yield significant reductions in unadjusted rates of mortality, cardiopulmonary arrest, or CD events.
Citation: Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system imple-mentation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33.
Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.