Clinical question: Is early surgery associated with better survival in patients with prosthetic valve endocarditis (PVE)?

Background: PVE occurs in 3% to 6% of patients within five years of valve implantation. Consensus guidelines, based on expert opinion, recommend surgical intervention with debridement and valve replacement in PVE, especially for patients with complications that are unlikely to be successfully treated with medical therapy, such as valve dysfunction, heart failure, and cardiac abscesses. Studies comparing survival with medical therapy versus surgery have reported conflicting results.

Study Design: Multi-center, prospective, cohort study.

Setting: International, multi-center cohort of patients from tertiary care hospitals.

Synopsis: The International Collaboration on Endocarditis—Prospective Cohort Study (ICE-PCS) cohort consisted of 1025 patients with PVE, 490 of whom underwent early surgery and 535 of whom received medical therapy alone.

Unadjusted initial analysis showed early surgery was associated with lower mortality; however, this survival benefit was not evident after the data was adjusted for treatment selection bias and survivor bias for in-hospital mortality and one-year mortality. The hazard ratios were 0.9 (95% CI 0.76 -1.07) and 1.04 (95% CI 0.89 -1.23), respectively.

Subgroup analysis indicated that early surgery in patients with high-risk features was associated with fewer poor outcomes compared to medical therapy: 28% versus 50% (P=.007)

Bottom line: Early surgery may not be associated with mortality benefits for PVE. High-risk patients, however, still might benefit from early surgery.

Citation: Lalani T, Chu VH, Park LP, et al. In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis. JAMA Intern Med. 2013:173:1495-1504.

Clinical question: Is early surgery associated with better survival in patients with prosthetic valve endocarditis (PVE)?

Background: PVE occurs in 3% to 6% of patients within five years of valve implantation. Consensus guidelines, based on expert opinion, recommend surgical intervention with debridement and valve replacement in PVE, especially for patients with complications that are unlikely to be successfully treated with medical therapy, such as valve dysfunction, heart failure, and cardiac abscesses. Studies comparing survival with medical therapy versus surgery have reported conflicting results.

Study Design: Multi-center, prospective, cohort study.

Setting: International, multi-center cohort of patients from tertiary care hospitals.

Synopsis: The International Collaboration on Endocarditis—Prospective Cohort Study (ICE-PCS) cohort consisted of 1025 patients with PVE, 490 of whom underwent early surgery and 535 of whom received medical therapy alone.

Unadjusted initial analysis showed early surgery was associated with lower mortality; however, this survival benefit was not evident after the data was adjusted for treatment selection bias and survivor bias for in-hospital mortality and one-year mortality. The hazard ratios were 0.9 (95% CI 0.76 -1.07) and 1.04 (95% CI 0.89 -1.23), respectively.

Subgroup analysis indicated that early surgery in patients with high-risk features was associated with fewer poor outcomes compared to medical therapy: 28% versus 50% (P=.007)

Bottom line: Early surgery may not be associated with mortality benefits for PVE. High-risk patients, however, still might benefit from early surgery.

Citation: Lalani T, Chu VH, Park LP, et al. In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis. JAMA Intern Med. 2013:173:1495-1504.

Clinical question: Is early surgery associated with better survival in patients with prosthetic valve endocarditis (PVE)?

Background: PVE occurs in 3% to 6% of patients within five years of valve implantation. Consensus guidelines, based on expert opinion, recommend surgical intervention with debridement and valve replacement in PVE, especially for patients with complications that are unlikely to be successfully treated with medical therapy, such as valve dysfunction, heart failure, and cardiac abscesses. Studies comparing survival with medical therapy versus surgery have reported conflicting results.

Study Design: Multi-center, prospective, cohort study.

Setting: International, multi-center cohort of patients from tertiary care hospitals.

Synopsis: The International Collaboration on Endocarditis—Prospective Cohort Study (ICE-PCS) cohort consisted of 1025 patients with PVE, 490 of whom underwent early surgery and 535 of whom received medical therapy alone.

Unadjusted initial analysis showed early surgery was associated with lower mortality; however, this survival benefit was not evident after the data was adjusted for treatment selection bias and survivor bias for in-hospital mortality and one-year mortality. The hazard ratios were 0.9 (95% CI 0.76 -1.07) and 1.04 (95% CI 0.89 -1.23), respectively.

Subgroup analysis indicated that early surgery in patients with high-risk features was associated with fewer poor outcomes compared to medical therapy: 28% versus 50% (P=.007)

Bottom line: Early surgery may not be associated with mortality benefits for PVE. High-risk patients, however, still might benefit from early surgery.

Citation: Lalani T, Chu VH, Park LP, et al. In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis. JAMA Intern Med. 2013:173:1495-1504.

Clinical question: What steps can hospitals take to reduce readmission rates in patients with heart failure?

Background: Evidence about various hospital strategies to decrease readmissions in patients with heart failure is limited.

Study Design: Cross-sectional study using a web-based survey.

Setting: Survey of 599 hospitals participating in quality initiatives to reduce readmissions.

Synopsis: Readmission of patients with heart failure is common and costly. Hospitals with high readmissions can lose up to 3% of their Medicare reimbursements by 2015.

This study found six strategies associated with lower risk-standardized 30-day readmission rates.

1. Partnering with community physicians and physician groups (0.33%; P=0.017);
2. Partnering with local hospitals (0.34%; P=0.020);
3. Having nurses responsible for medication reconciliation (0.18%; P=0.002);
4. Arranging follow-up visit before discharge (0.19%; P=0.037);
5. Having a process in place to send all discharge summaries directly to the patient’s primary care physician (0.21%; P=0.004); and
6. Assigning staff to follow up on test results after the patient is discharged (0.26%; P=0.049).

Individually, the magnitude of the effects was modest, but implementing multiple strategies was more beneficial (0.34% additional benefit for each additional strategy). Only 7% of the hospitals surveyed implemented all six strategies, highlighting substantial opportunities for improvement.

Bottom line: Implementing multiple strategies may help reduce readmission in patients with heart failure.

Citation: Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.

Clinical question: What steps can hospitals take to reduce readmission rates in patients with heart failure?

Background: Evidence about various hospital strategies to decrease readmissions in patients with heart failure is limited.

Study Design: Cross-sectional study using a web-based survey.

Setting: Survey of 599 hospitals participating in quality initiatives to reduce readmissions.

Synopsis: Readmission of patients with heart failure is common and costly. Hospitals with high readmissions can lose up to 3% of their Medicare reimbursements by 2015.

This study found six strategies associated with lower risk-standardized 30-day readmission rates.

1. Partnering with community physicians and physician groups (0.33%; P=0.017);
2. Partnering with local hospitals (0.34%; P=0.020);
3. Having nurses responsible for medication reconciliation (0.18%; P=0.002);
4. Arranging follow-up visit before discharge (0.19%; P=0.037);
5. Having a process in place to send all discharge summaries directly to the patient’s primary care physician (0.21%; P=0.004); and
6. Assigning staff to follow up on test results after the patient is discharged (0.26%; P=0.049).

Individually, the magnitude of the effects was modest, but implementing multiple strategies was more beneficial (0.34% additional benefit for each additional strategy). Only 7% of the hospitals surveyed implemented all six strategies, highlighting substantial opportunities for improvement.

Bottom line: Implementing multiple strategies may help reduce readmission in patients with heart failure.

Citation: Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.

Clinical question: What steps can hospitals take to reduce readmission rates in patients with heart failure?

Background: Evidence about various hospital strategies to decrease readmissions in patients with heart failure is limited.

Study Design: Cross-sectional study using a web-based survey.

Setting: Survey of 599 hospitals participating in quality initiatives to reduce readmissions.

Synopsis: Readmission of patients with heart failure is common and costly. Hospitals with high readmissions can lose up to 3% of their Medicare reimbursements by 2015.

This study found six strategies associated with lower risk-standardized 30-day readmission rates.

1. Partnering with community physicians and physician groups (0.33%; P=0.017);
2. Partnering with local hospitals (0.34%; P=0.020);
3. Having nurses responsible for medication reconciliation (0.18%; P=0.002);
4. Arranging follow-up visit before discharge (0.19%; P=0.037);
5. Having a process in place to send all discharge summaries directly to the patient’s primary care physician (0.21%; P=0.004); and
6. Assigning staff to follow up on test results after the patient is discharged (0.26%; P=0.049).

Individually, the magnitude of the effects was modest, but implementing multiple strategies was more beneficial (0.34% additional benefit for each additional strategy). Only 7% of the hospitals surveyed implemented all six strategies, highlighting substantial opportunities for improvement.

Bottom line: Implementing multiple strategies may help reduce readmission in patients with heart failure.

Citation: Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: How have opioid pain reliever (OPR) prescriptions affected drug misuse or abuse and drug overdose deaths for women in the past decade?

Background: Overdose deaths have increased steadily over the past decade. More men die from drug overdoses, but the percentage of women dying from drug misuse has increased substantially.

Study design: Retrospective analysis.

Setting: Data from the National Vital Statistics System (NVSS) and the Drug Abuse Warning Network (DAWN).

Synopsis: The CDC analyzed death rates based on NVSS multiple causes of death from 1999-2010. Type of drug involved (OPR, cocaine, heroin, benzodiazepines) was based on ICD 10 codes. Analysis showed that deaths from OPRs between 1999 and 2010 increased five-fold in women, compared to 3.6-fold in men.

The CDC also analyzed DAWN data from ED visits by women for drug misuse or abuse between 2004-2010. When compared to data from 2004, the ED visits related to misuse or abuse of OPR among women more than doubled, and the rate of OPR deaths among women increased by 70%.

Limitations of this study include the fact that all drugs used were not identified, and motivation to use was unclear. Also, medical or non-medical reason for use was not always available.

Bottom line: Healthcare providers prescribing OPRs to patients should use their state’s prescription drug monitoring program and regularly screen patients for psychological disorders and use of psychotherapeutic drugs, with or without a prescription.

Citation: Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542.

Clinical question: How have opioid pain reliever (OPR) prescriptions affected drug misuse or abuse and drug overdose deaths for women in the past decade?

Background: Overdose deaths have increased steadily over the past decade. More men die from drug overdoses, but the percentage of women dying from drug misuse has increased substantially.

Study design: Retrospective analysis.

Setting: Data from the National Vital Statistics System (NVSS) and the Drug Abuse Warning Network (DAWN).

Synopsis: The CDC analyzed death rates based on NVSS multiple causes of death from 1999-2010. Type of drug involved (OPR, cocaine, heroin, benzodiazepines) was based on ICD 10 codes. Analysis showed that deaths from OPRs between 1999 and 2010 increased five-fold in women, compared to 3.6-fold in men.

The CDC also analyzed DAWN data from ED visits by women for drug misuse or abuse between 2004-2010. When compared to data from 2004, the ED visits related to misuse or abuse of OPR among women more than doubled, and the rate of OPR deaths among women increased by 70%.

Limitations of this study include the fact that all drugs used were not identified, and motivation to use was unclear. Also, medical or non-medical reason for use was not always available.

Bottom line: Healthcare providers prescribing OPRs to patients should use their state’s prescription drug monitoring program and regularly screen patients for psychological disorders and use of psychotherapeutic drugs, with or without a prescription.

Citation: Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542.

Clinical question: How have opioid pain reliever (OPR) prescriptions affected drug misuse or abuse and drug overdose deaths for women in the past decade?

Background: Overdose deaths have increased steadily over the past decade. More men die from drug overdoses, but the percentage of women dying from drug misuse has increased substantially.

Study design: Retrospective analysis.

Setting: Data from the National Vital Statistics System (NVSS) and the Drug Abuse Warning Network (DAWN).

Synopsis: The CDC analyzed death rates based on NVSS multiple causes of death from 1999-2010. Type of drug involved (OPR, cocaine, heroin, benzodiazepines) was based on ICD 10 codes. Analysis showed that deaths from OPRs between 1999 and 2010 increased five-fold in women, compared to 3.6-fold in men.

The CDC also analyzed DAWN data from ED visits by women for drug misuse or abuse between 2004-2010. When compared to data from 2004, the ED visits related to misuse or abuse of OPR among women more than doubled, and the rate of OPR deaths among women increased by 70%.

Limitations of this study include the fact that all drugs used were not identified, and motivation to use was unclear. Also, medical or non-medical reason for use was not always available.

Bottom line: Healthcare providers prescribing OPRs to patients should use their state’s prescription drug monitoring program and regularly screen patients for psychological disorders and use of psychotherapeutic drugs, with or without a prescription.

Citation: Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What patient-risk factors predict superficial and deep/organ-space surgical site infections (SSIs) following colectomy procedures?

Background: SSIs are often targeted by policymakers for quality improvement and cost saving. Superficial and deep/organ-specific SSIs are traditionally considered a single entity for quality measurement, although they vary by anatomic location and clinical severity.

Study design: Retrospective cohort study.

Setting: American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP).

Synopsis: Researchers used the ACS-NSQIP registry to identify all patients who underwent colectomy procedures across 305 hospitals. Various patient variables, such as demographics, pre-operative risk factors, comorbidities, and operative information, were collected on all patients. The primary outcome was 30-day post-operative superficial SSI and deep/organ-space SSI.

Overall, 27,011 patients underwent colectomy procedures, of which 6.2% developed a superficial SSI and 4.7% developed deep/organ-space SSI. Open surgical approach (vs. laparoscopic) and current smoking were the only risk factors that predicted the occurrence of both superficial and deep/organ-space SSI. Other risk factors (e.g., post-operative diagnoses, disseminated cancer, and irradiation therapy) had a differential effect and only predicted the occurrence of deep/organ-space SSI. Elevated body mass index was strongly correlated with the occurrence of superficial SSI.

Key limitations of the study included unavailability of infection rates beyond 30 days and grouping of deep and organ-space SSIs, as the latter might vary in magnitude and significance.

Bottom Line: Risk factors that predict superficial and deep/organ-space SSI differ significantly, suggesting that future quality initiatives and reporting should evaluate different types of SSIs independently.

Citation: Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs. deep/organ-space surgical site infections: implications for quality improvement initiatives [published online ahead of print July 17, 2013]. JAMA Surg.

Clinical question: What patient-risk factors predict superficial and deep/organ-space surgical site infections (SSIs) following colectomy procedures?

Background: SSIs are often targeted by policymakers for quality improvement and cost saving. Superficial and deep/organ-specific SSIs are traditionally considered a single entity for quality measurement, although they vary by anatomic location and clinical severity.

Study design: Retrospective cohort study.

Setting: American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP).

Synopsis: Researchers used the ACS-NSQIP registry to identify all patients who underwent colectomy procedures across 305 hospitals. Various patient variables, such as demographics, pre-operative risk factors, comorbidities, and operative information, were collected on all patients. The primary outcome was 30-day post-operative superficial SSI and deep/organ-space SSI.

Overall, 27,011 patients underwent colectomy procedures, of which 6.2% developed a superficial SSI and 4.7% developed deep/organ-space SSI. Open surgical approach (vs. laparoscopic) and current smoking were the only risk factors that predicted the occurrence of both superficial and deep/organ-space SSI. Other risk factors (e.g., post-operative diagnoses, disseminated cancer, and irradiation therapy) had a differential effect and only predicted the occurrence of deep/organ-space SSI. Elevated body mass index was strongly correlated with the occurrence of superficial SSI.

Key limitations of the study included unavailability of infection rates beyond 30 days and grouping of deep and organ-space SSIs, as the latter might vary in magnitude and significance.

Bottom Line: Risk factors that predict superficial and deep/organ-space SSI differ significantly, suggesting that future quality initiatives and reporting should evaluate different types of SSIs independently.

Citation: Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs. deep/organ-space surgical site infections: implications for quality improvement initiatives [published online ahead of print July 17, 2013]. JAMA Surg.

Clinical question: What patient-risk factors predict superficial and deep/organ-space surgical site infections (SSIs) following colectomy procedures?

Background: SSIs are often targeted by policymakers for quality improvement and cost saving. Superficial and deep/organ-specific SSIs are traditionally considered a single entity for quality measurement, although they vary by anatomic location and clinical severity.

Study design: Retrospective cohort study.

Setting: American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP).

Synopsis: Researchers used the ACS-NSQIP registry to identify all patients who underwent colectomy procedures across 305 hospitals. Various patient variables, such as demographics, pre-operative risk factors, comorbidities, and operative information, were collected on all patients. The primary outcome was 30-day post-operative superficial SSI and deep/organ-space SSI.

Overall, 27,011 patients underwent colectomy procedures, of which 6.2% developed a superficial SSI and 4.7% developed deep/organ-space SSI. Open surgical approach (vs. laparoscopic) and current smoking were the only risk factors that predicted the occurrence of both superficial and deep/organ-space SSI. Other risk factors (e.g., post-operative diagnoses, disseminated cancer, and irradiation therapy) had a differential effect and only predicted the occurrence of deep/organ-space SSI. Elevated body mass index was strongly correlated with the occurrence of superficial SSI.

Key limitations of the study included unavailability of infection rates beyond 30 days and grouping of deep and organ-space SSIs, as the latter might vary in magnitude and significance.

Bottom Line: Risk factors that predict superficial and deep/organ-space SSI differ significantly, suggesting that future quality initiatives and reporting should evaluate different types of SSIs independently.

Citation: Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs. deep/organ-space surgical site infections: implications for quality improvement initiatives [published online ahead of print July 17, 2013]. JAMA Surg.

Dr. Hospitalist

Fellowships Available to Family Physicians Considering Hospital Medicine Career

I am in my final year of family practice residency. I discovered that I enjoyed hospital medicine much more than I thought I would. I am considering a hospitalist fellowship (one year) to add depth and breadth to my clinical skills. Do you view the clinical knowledge from a fellowship as beneficial to outpatient practice, and, with respect to hospitalist opportunities, are they available to an FP physician?

–Ward Harbin, MD

Dr. Hospitalist responds:

Congratulations on completing your residency. I know it has been a long and arduous journey, but you’re almost there!

I do believe HM fellowships are beneficial for anyone aspiring to become a hospitalist. Even though fewer than 5% of U.S. hospitalists are family practice graduates, there are many opportunities for FP residents to do a fellowship in hospital medicine. Many hospitalist programs limit their recruitment to board-certified internal medicine candidates, but this is probably more a reflection of internists having sustained a foothold in the HM movement and staking out their turf. Nearly all fellowships are one year in length, and most only offer one or two slots. As you can imagine, with such a limited number of positions, the competition is fairly keen, especially in the larger academic programs.

Most programs offer core rotations (similar to residency) but allow some flexibility in selection of electives. Some programs offer several different tracks. For example, Mayo Clinic in Rochester, Minn., offers clinical research, clinician educator, and quality tracks. These are becoming more popular, as they allow the fellow to focus early on a particular area of hospital medicine and, ideally, develop a niche, while becoming a much more attractive candidate for employment.

If I were considering the practice of outpatient adult medicine, I would think about a fellowship in general medicine and target a specific area (e.g., geriatrics or sports medicine). For many reasons, these tend to be less competitive, but as our population ages and current reimbursement strategies are challenged, this may soon change. While there are many clinical principles taught in an HM fellowship that are applicable to outpatient medicine, it would be best to choose the area of interest (inpatient vs. outpatient) and focus your efforts in that direction.

As hospitalists are increasingly being offered more administrative opportunities, several post-graduate degrees or areas of focus are becoming valuable. I would strongly consider pursuing a master’s degree in healthcare management (MHM) or healthcare administration (MHA). Those degrees are offered by a number of top-notch business schools. Nearly all are two-year programs with built-in schedule flexibility, basically geared toward the working professional. A master’s degree in public health (MPH) is also a valued degree and is offered by many outstanding programs. Although most programs attempt to emphasize and train healthcare professionals for the public health arena, there are opportunities to specialize in areas that can be used in hospital management.

As the hospitalist movement matures and the healthcare industry evolves due to market and governmental pressures, there will be many more administrative and clinical opportunities for hospitalists. The clinicians best positioned to take advantage of these opportunities will be those who have some form of post-graduate training supported by strong clinical skills.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

Fellowships Available to Family Physicians Considering Hospital Medicine Career

I am in my final year of family practice residency. I discovered that I enjoyed hospital medicine much more than I thought I would. I am considering a hospitalist fellowship (one year) to add depth and breadth to my clinical skills. Do you view the clinical knowledge from a fellowship as beneficial to outpatient practice, and, with respect to hospitalist opportunities, are they available to an FP physician?

–Ward Harbin, MD

Dr. Hospitalist responds:

Congratulations on completing your residency. I know it has been a long and arduous journey, but you’re almost there!

I do believe HM fellowships are beneficial for anyone aspiring to become a hospitalist. Even though fewer than 5% of U.S. hospitalists are family practice graduates, there are many opportunities for FP residents to do a fellowship in hospital medicine. Many hospitalist programs limit their recruitment to board-certified internal medicine candidates, but this is probably more a reflection of internists having sustained a foothold in the HM movement and staking out their turf. Nearly all fellowships are one year in length, and most only offer one or two slots. As you can imagine, with such a limited number of positions, the competition is fairly keen, especially in the larger academic programs.

Most programs offer core rotations (similar to residency) but allow some flexibility in selection of electives. Some programs offer several different tracks. For example, Mayo Clinic in Rochester, Minn., offers clinical research, clinician educator, and quality tracks. These are becoming more popular, as they allow the fellow to focus early on a particular area of hospital medicine and, ideally, develop a niche, while becoming a much more attractive candidate for employment.

If I were considering the practice of outpatient adult medicine, I would think about a fellowship in general medicine and target a specific area (e.g., geriatrics or sports medicine). For many reasons, these tend to be less competitive, but as our population ages and current reimbursement strategies are challenged, this may soon change. While there are many clinical principles taught in an HM fellowship that are applicable to outpatient medicine, it would be best to choose the area of interest (inpatient vs. outpatient) and focus your efforts in that direction.

As hospitalists are increasingly being offered more administrative opportunities, several post-graduate degrees or areas of focus are becoming valuable. I would strongly consider pursuing a master’s degree in healthcare management (MHM) or healthcare administration (MHA). Those degrees are offered by a number of top-notch business schools. Nearly all are two-year programs with built-in schedule flexibility, basically geared toward the working professional. A master’s degree in public health (MPH) is also a valued degree and is offered by many outstanding programs. Although most programs attempt to emphasize and train healthcare professionals for the public health arena, there are opportunities to specialize in areas that can be used in hospital management.

As the hospitalist movement matures and the healthcare industry evolves due to market and governmental pressures, there will be many more administrative and clinical opportunities for hospitalists. The clinicians best positioned to take advantage of these opportunities will be those who have some form of post-graduate training supported by strong clinical skills.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

Fellowships Available to Family Physicians Considering Hospital Medicine Career

I am in my final year of family practice residency. I discovered that I enjoyed hospital medicine much more than I thought I would. I am considering a hospitalist fellowship (one year) to add depth and breadth to my clinical skills. Do you view the clinical knowledge from a fellowship as beneficial to outpatient practice, and, with respect to hospitalist opportunities, are they available to an FP physician?

–Ward Harbin, MD

Dr. Hospitalist responds:

Congratulations on completing your residency. I know it has been a long and arduous journey, but you’re almost there!

I do believe HM fellowships are beneficial for anyone aspiring to become a hospitalist. Even though fewer than 5% of U.S. hospitalists are family practice graduates, there are many opportunities for FP residents to do a fellowship in hospital medicine. Many hospitalist programs limit their recruitment to board-certified internal medicine candidates, but this is probably more a reflection of internists having sustained a foothold in the HM movement and staking out their turf. Nearly all fellowships are one year in length, and most only offer one or two slots. As you can imagine, with such a limited number of positions, the competition is fairly keen, especially in the larger academic programs.

Most programs offer core rotations (similar to residency) but allow some flexibility in selection of electives. Some programs offer several different tracks. For example, Mayo Clinic in Rochester, Minn., offers clinical research, clinician educator, and quality tracks. These are becoming more popular, as they allow the fellow to focus early on a particular area of hospital medicine and, ideally, develop a niche, while becoming a much more attractive candidate for employment.

If I were considering the practice of outpatient adult medicine, I would think about a fellowship in general medicine and target a specific area (e.g., geriatrics or sports medicine). For many reasons, these tend to be less competitive, but as our population ages and current reimbursement strategies are challenged, this may soon change. While there are many clinical principles taught in an HM fellowship that are applicable to outpatient medicine, it would be best to choose the area of interest (inpatient vs. outpatient) and focus your efforts in that direction.

As hospitalists are increasingly being offered more administrative opportunities, several post-graduate degrees or areas of focus are becoming valuable. I would strongly consider pursuing a master’s degree in healthcare management (MHM) or healthcare administration (MHA). Those degrees are offered by a number of top-notch business schools. Nearly all are two-year programs with built-in schedule flexibility, basically geared toward the working professional. A master’s degree in public health (MPH) is also a valued degree and is offered by many outstanding programs. Although most programs attempt to emphasize and train healthcare professionals for the public health arena, there are opportunities to specialize in areas that can be used in hospital management.

As the hospitalist movement matures and the healthcare industry evolves due to market and governmental pressures, there will be many more administrative and clinical opportunities for hospitalists. The clinicians best positioned to take advantage of these opportunities will be those who have some form of post-graduate training supported by strong clinical skills.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Clinical question: Is apixaban non-inferior to standard therapy for treating acute VTE?

Background: Apixaban, a direct Xa inhibitor, has not been tested for efficacy and safety in treating acute VTE. Rivaroxaban, another direct Xa inhibitor, is already FDA-approved for acute VTE treatment.

Study design: Randomized, double-blinded trial.

Setting: International multi-center.

Synopsis: Researchers randomized 5400 patients with acute VTE to receive either apixaban (10 mg po bid x 7 days, then 5 mg po bid x 6 months) + placebo, or lovenox with transition to coumadin, with a goal of international normalized ratio 2-3. Recurrent VTE occurred in 2.3% of the apixaban group, compared with 2.7% in the conventional therapy group (apixaban noninferior). Major bleeding occurred less in the apixaban group than in the conventional therapy group (0.6% compared to 1.8%), as did clinically relevant non-major bleeding (3.8% compared to 8%).

Bottom line: Apixaban is a safe alternative for treating acute VTE (pending FDA approval).

Citation: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. New Engl J Med. 2013;369:799-808.

Clinical question: Is apixaban non-inferior to standard therapy for treating acute VTE?

Background: Apixaban, a direct Xa inhibitor, has not been tested for efficacy and safety in treating acute VTE. Rivaroxaban, another direct Xa inhibitor, is already FDA-approved for acute VTE treatment.

Study design: Randomized, double-blinded trial.

Setting: International multi-center.

Synopsis: Researchers randomized 5400 patients with acute VTE to receive either apixaban (10 mg po bid x 7 days, then 5 mg po bid x 6 months) + placebo, or lovenox with transition to coumadin, with a goal of international normalized ratio 2-3. Recurrent VTE occurred in 2.3% of the apixaban group, compared with 2.7% in the conventional therapy group (apixaban noninferior). Major bleeding occurred less in the apixaban group than in the conventional therapy group (0.6% compared to 1.8%), as did clinically relevant non-major bleeding (3.8% compared to 8%).

Bottom line: Apixaban is a safe alternative for treating acute VTE (pending FDA approval).

Citation: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. New Engl J Med. 2013;369:799-808.

Clinical question: Is apixaban non-inferior to standard therapy for treating acute VTE?

Background: Apixaban, a direct Xa inhibitor, has not been tested for efficacy and safety in treating acute VTE. Rivaroxaban, another direct Xa inhibitor, is already FDA-approved for acute VTE treatment.

Study design: Randomized, double-blinded trial.

Setting: International multi-center.

Synopsis: Researchers randomized 5400 patients with acute VTE to receive either apixaban (10 mg po bid x 7 days, then 5 mg po bid x 6 months) + placebo, or lovenox with transition to coumadin, with a goal of international normalized ratio 2-3. Recurrent VTE occurred in 2.3% of the apixaban group, compared with 2.7% in the conventional therapy group (apixaban noninferior). Major bleeding occurred less in the apixaban group than in the conventional therapy group (0.6% compared to 1.8%), as did clinically relevant non-major bleeding (3.8% compared to 8%).

Bottom line: Apixaban is a safe alternative for treating acute VTE (pending FDA approval).

Citation: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. New Engl J Med. 2013;369:799-808.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].