Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).

Question: What type of business do you operate?

Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.

Q: Why did you give up the practice of medicine?

A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.

In short, I was deeply restless, in my early 40s, and ready for a change.

Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?

A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.

Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.

Q: Can you name some pros and cons for physicians interested in a career change?

A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.

The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.

Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).

Question: What type of business do you operate?

Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.

Q: Why did you give up the practice of medicine?

A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.

In short, I was deeply restless, in my early 40s, and ready for a change.

Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?

A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.

Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.

Q: Can you name some pros and cons for physicians interested in a career change?

A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.

The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.

Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).

Question: What type of business do you operate?

Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.

Q: Why did you give up the practice of medicine?

A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.

In short, I was deeply restless, in my early 40s, and ready for a change.

Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?

A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.

Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.

Q: Can you name some pros and cons for physicians interested in a career change?

A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.

The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Hospitalist and former SHM president Patrick Cawley, MD, MBA, MHM, has been named vice president for clinical operations and executive director of the Medical University Hospital Authority at the Medical University of South Carolina (MUSC). Dr. Cawley is MUSC’s executive medical director and chief medical officer. He starts his new position in April.

Amina Ahmed, MD, has been named director of hospitalist medicine at Summit Medical Group in Berkeley Heights, N.J. Prior to 2008, when she first joined Summit, Dr. Ahmed served as an internist with privileges at several northern New Jersey facilities, including Christ Hospital, Jersey City Medical Center, and Hamilton Park Rehabilitation Center. In addition to hospital medicine, Dr. Ahmed also specializes in cardiovascular medicine.

Michael Tofano, MD, has been named hospitalist director at John T. Mather Memorial Hospital in Port Jefferson, N.Y. Dr. Tofano previously was the HM director at UMass Memorial Health Care’s hospitals in Marlborough, Mass., and Clinton, Mass. He also served as associate chief of HM at UMass Memorial Health Care in Worcester. Dr. Tofano’s training is in hospital medicine with a focus on cardiology.

Hospitalist Valerie Carter of Baptist Memorial Hospital Union County in New Albany, Miss., was recently given the DAISY Award for Extraordinary Nurses. Candidates for the award are nominated by hospital patients and their families and ultimately chosen by supervisors in the hospital’s nursing department.

Business Moves

North Hollywood, Calif.-based IPC: The Hospitalist Co. has announced the acquisitions of two new acute-care practices—Midwest Acute Care Consultants in St. Louis and AHCP of southeastern Michigan. IPC now provides and oversees hospitalist and post-acute-care practices in 28 states.

Knoxville, Tenn.-based TeamHealth, a provider of hospitalist services throughout the U.S., recently announced its acquisition of two private emergency medicine providers and one private anesthesiology firm. TeamHealth will administer ED services at San Ramon Regional Medical Center in San Ramon, Calif., and Mobile Emergency Group in Mobile, Ala. The firm also will oversee operations at hospitals served by Northern Valley Anesthesiology in Englewood, N.J.

Hospitalists at San Francisco-based Galen Inpatient Physicians are now partners with CEP America, a physician staffing firm based in Emeryville, Calif. Founded in 1975, CEP provides acute-care practice management, as well as hospitalist services to more than 100 facilities in eight states. Galen has provided hospitalist services since 2000.

Hospitalist and former SHM president Patrick Cawley, MD, MBA, MHM, has been named vice president for clinical operations and executive director of the Medical University Hospital Authority at the Medical University of South Carolina (MUSC). Dr. Cawley is MUSC’s executive medical director and chief medical officer. He starts his new position in April.

Amina Ahmed, MD, has been named director of hospitalist medicine at Summit Medical Group in Berkeley Heights, N.J. Prior to 2008, when she first joined Summit, Dr. Ahmed served as an internist with privileges at several northern New Jersey facilities, including Christ Hospital, Jersey City Medical Center, and Hamilton Park Rehabilitation Center. In addition to hospital medicine, Dr. Ahmed also specializes in cardiovascular medicine.

Michael Tofano, MD, has been named hospitalist director at John T. Mather Memorial Hospital in Port Jefferson, N.Y. Dr. Tofano previously was the HM director at UMass Memorial Health Care’s hospitals in Marlborough, Mass., and Clinton, Mass. He also served as associate chief of HM at UMass Memorial Health Care in Worcester. Dr. Tofano’s training is in hospital medicine with a focus on cardiology.

Hospitalist Valerie Carter of Baptist Memorial Hospital Union County in New Albany, Miss., was recently given the DAISY Award for Extraordinary Nurses. Candidates for the award are nominated by hospital patients and their families and ultimately chosen by supervisors in the hospital’s nursing department.

Business Moves

North Hollywood, Calif.-based IPC: The Hospitalist Co. has announced the acquisitions of two new acute-care practices—Midwest Acute Care Consultants in St. Louis and AHCP of southeastern Michigan. IPC now provides and oversees hospitalist and post-acute-care practices in 28 states.

Knoxville, Tenn.-based TeamHealth, a provider of hospitalist services throughout the U.S., recently announced its acquisition of two private emergency medicine providers and one private anesthesiology firm. TeamHealth will administer ED services at San Ramon Regional Medical Center in San Ramon, Calif., and Mobile Emergency Group in Mobile, Ala. The firm also will oversee operations at hospitals served by Northern Valley Anesthesiology in Englewood, N.J.

Hospitalists at San Francisco-based Galen Inpatient Physicians are now partners with CEP America, a physician staffing firm based in Emeryville, Calif. Founded in 1975, CEP provides acute-care practice management, as well as hospitalist services to more than 100 facilities in eight states. Galen has provided hospitalist services since 2000.

Hospitalist and former SHM president Patrick Cawley, MD, MBA, MHM, has been named vice president for clinical operations and executive director of the Medical University Hospital Authority at the Medical University of South Carolina (MUSC). Dr. Cawley is MUSC’s executive medical director and chief medical officer. He starts his new position in April.

Amina Ahmed, MD, has been named director of hospitalist medicine at Summit Medical Group in Berkeley Heights, N.J. Prior to 2008, when she first joined Summit, Dr. Ahmed served as an internist with privileges at several northern New Jersey facilities, including Christ Hospital, Jersey City Medical Center, and Hamilton Park Rehabilitation Center. In addition to hospital medicine, Dr. Ahmed also specializes in cardiovascular medicine.

Michael Tofano, MD, has been named hospitalist director at John T. Mather Memorial Hospital in Port Jefferson, N.Y. Dr. Tofano previously was the HM director at UMass Memorial Health Care’s hospitals in Marlborough, Mass., and Clinton, Mass. He also served as associate chief of HM at UMass Memorial Health Care in Worcester. Dr. Tofano’s training is in hospital medicine with a focus on cardiology.

Hospitalist Valerie Carter of Baptist Memorial Hospital Union County in New Albany, Miss., was recently given the DAISY Award for Extraordinary Nurses. Candidates for the award are nominated by hospital patients and their families and ultimately chosen by supervisors in the hospital’s nursing department.

Business Moves

North Hollywood, Calif.-based IPC: The Hospitalist Co. has announced the acquisitions of two new acute-care practices—Midwest Acute Care Consultants in St. Louis and AHCP of southeastern Michigan. IPC now provides and oversees hospitalist and post-acute-care practices in 28 states.

Knoxville, Tenn.-based TeamHealth, a provider of hospitalist services throughout the U.S., recently announced its acquisition of two private emergency medicine providers and one private anesthesiology firm. TeamHealth will administer ED services at San Ramon Regional Medical Center in San Ramon, Calif., and Mobile Emergency Group in Mobile, Ala. The firm also will oversee operations at hospitals served by Northern Valley Anesthesiology in Englewood, N.J.

Hospitalists at San Francisco-based Galen Inpatient Physicians are now partners with CEP America, a physician staffing firm based in Emeryville, Calif. Founded in 1975, CEP provides acute-care practice management, as well as hospitalist services to more than 100 facilities in eight states. Galen has provided hospitalist services since 2000.

Background

In the U.S. alone, there are an estimated 25.8 million people with diabetes, or about 8.3% of the population. Due to comorbidities of peripheral neuropathy and peripheral vascular disease associated with diabetes, these patients are at higher risk for developing foot infections. Among the myriad diabetes complications, diabetic foot infections (DFI) are the main reason for diabetes-related hospitalizations and lower-extremity amputations. U.S. hospitals admit roughly 5,700 patients per year for DFI; 71,000 lower-extremity amputations are attributed to diabetes.^1,2

Studies have demonstrated that DFI management according to guidelines improves survival, reduces complications, and is cost-effective with a major clinical outcome of reduced amputations.³ But prospective observational studies have shown that, in practice, guidelines often are not followed and can lead to poor outcomes.⁴ Studies suggest a need for more simple, straightforward guidelines.

Guidelines Update

In June 2012, the Infectious Diseases Society of America (IDSA) updated its 2004 guidelines on the management of diabetic foot infections.⁵ Although IDSA made no major changes to its recommendations, the 2012 guidelines were revised to be more simple and clear. These new guidelines have been reviewed and endorsed by SHM.

Specific recommendations include:

• All patients with suspected DFI should be assessed on three levels: the patient, the extremity involved, and the wound. Patients should be assessed for signs of systemic illness or metabolic derangements. The extremity should be examined for peripheral arterial disease (PAD) using the Ankle-Brachial Index (ABI), and those with an ABI <0.4 should be evaluated by a vascular surgeon.
• Uninfected wounds should be distinguished from infected wounds based on the presence of two or more classic signs of inflammation and purulence. All wounds should be classified based on validated systems, such as those established by IDSA or the International Working Group on the Diabetic Foot (IWGDF). The IDSA classification of wounds as uninfected, mild, moderate, and severe correlate well with the IWGDF’s PEDIS (Perfusion, Extent, Depth, Infection and Sensation) Grades 1, 2, 3, and 4. Wounds are distinguished by size (more or less than 2 cm in width), extent (depth of tissue involvement), and the presence of two or more signs of systemic inflammatory response syndrome.
• Whenever possible, management of DFI should involve multidisciplinary teams that include a microbiologist or ID expert, surgeon/podiatrist familiar with debridement of foot infections, and wound care experts familiar with dressings that provide pressure off-loading.
• All wounds should be debrided, and cultures should be sent from deep tissue via biopsy or curettage (scraping of the base of the ulcer). Wound surface swabs should not be sent for culture, as they often are inaccurate.
• All patients with severe infections and some patients with moderate infections with complicating features (i.e. severe PAD or inability to manage outpatient treatment due to psychosocial reasons) should be admitted. Those with mild infection or some moderate infections without complicating features can be managed as outpatients.
• All patients with suspected DFI should have plain radiographs of the affected limb to evaluate for bony abnormalities, soft-tissue gas, or foreign bodies, but they are only 54% sensitive and 68% specific for osteomyelitis. MRI is more sensitive (90%) and specific (up to 90%) for detecting osteomyelitis. When MRI is contraindicated, a bone scan coupled with a tagged white-blood count scan is the next best test for detecting osteomyelitis.
• Osteomyelitis, which is found in as many as 20% of mild to moderate DFI cases and as many as 50% of severe DFI cases, should be suspected in any patient with large (>2 cm square), deep, or chronic (>six weeks) wounds, as well as those who have wounds overlying a bony prominence or have a positive probe-to-bone (PTB) test. The most definitive diagnosis of osteomyelitis is via bone biopsy for culture and histology. Patients with osteomyelitis can be managed surgically with resection or medically with prolonged antibiotics (>four weeks). If surgical resection removes the infected bone with clean margins, the antibiotic course can be shortened to two to five days post-operatively.
• Effective treatment includes both wound care as well as antibiotic therapy. Antibiotics should be started after cultures are sent. Empiric antibiotics for mild to moderate infections in patients who have not been recently treated can be directed at gram-positive cocci (GPC), as Staphylococcus is the most common causal organism identified. Patients with severe infection can be started empirically on parenteral broad-spectrum antibiotics covering for GPC (particularly methicillin-resistant Staphylococcus aureus in at-risk patients), gram-negative bacteria, and obligate anaerobes. Antibiotics should be tailored once culture and sensitivity results are available. Generally, mild infections should be treated for one to two weeks and moderate to severe infections for two to three weeks, if there is no suspicion of osteomyelitis.

Analysis

The United Kingdom National Institute for Clinical Excellence (NICE) guideline development group published guidelines for inpatient management of diabetic foot problems in 2011.⁶ The NICE guidelines are largely similar to the 2012 IDSA guidelines. NICE guidelines call for each hospital to have a care pathway for all patients who present with a diabetic foot problem, and that these patients should be cared for by a multidisciplinary team, including appropriate wound care and debridement, assessment of vascular function, imaging with plain radiographs and MRI if osteomyelitis is suspected, and directed antibiotic therapy.

HM Takeaways

Diabetic foot infections are a common occurrence, and the guidelines for their management demonstrate how coordinated clinical care is important for improving patient care and outcomes. As health reimbursement moves toward a model of bundled payments for treatment and a greater emphasis on measureable outcomes, hospitalists are well positioned to be managers of such organized approaches with multidisciplinary teams.

Dr. Ly is a hospitalist in the division of hospital medicine at the University of California at San Francisco.

References

1. Centers for Disease Control and Prevention. Age-Adjusted Hospital Discharge Rates for Peripheral Arterial Disease (PAD), Ulcer/Inflammation/Infection (ULCER), or Neuropathy as First-Listed Diagnosis per 1,000 Diabetic Population, United States, 1988–2007. CDC website. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig2_pop.htm. Accessed Jan. 28, 2013.
2. Centers for Disease Control and Prevention. Number (in thousands) of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis, 1988-2006. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig1.htm. Accessed Jan. 28, 2013.
3. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18-25.
4. Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):132-173.
5. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011;342:d1280.

Background

In the U.S. alone, there are an estimated 25.8 million people with diabetes, or about 8.3% of the population. Due to comorbidities of peripheral neuropathy and peripheral vascular disease associated with diabetes, these patients are at higher risk for developing foot infections. Among the myriad diabetes complications, diabetic foot infections (DFI) are the main reason for diabetes-related hospitalizations and lower-extremity amputations. U.S. hospitals admit roughly 5,700 patients per year for DFI; 71,000 lower-extremity amputations are attributed to diabetes.^1,2

Studies have demonstrated that DFI management according to guidelines improves survival, reduces complications, and is cost-effective with a major clinical outcome of reduced amputations.³ But prospective observational studies have shown that, in practice, guidelines often are not followed and can lead to poor outcomes.⁴ Studies suggest a need for more simple, straightforward guidelines.

Guidelines Update

In June 2012, the Infectious Diseases Society of America (IDSA) updated its 2004 guidelines on the management of diabetic foot infections.⁵ Although IDSA made no major changes to its recommendations, the 2012 guidelines were revised to be more simple and clear. These new guidelines have been reviewed and endorsed by SHM.

Specific recommendations include:

• All patients with suspected DFI should be assessed on three levels: the patient, the extremity involved, and the wound. Patients should be assessed for signs of systemic illness or metabolic derangements. The extremity should be examined for peripheral arterial disease (PAD) using the Ankle-Brachial Index (ABI), and those with an ABI <0.4 should be evaluated by a vascular surgeon.
• Uninfected wounds should be distinguished from infected wounds based on the presence of two or more classic signs of inflammation and purulence. All wounds should be classified based on validated systems, such as those established by IDSA or the International Working Group on the Diabetic Foot (IWGDF). The IDSA classification of wounds as uninfected, mild, moderate, and severe correlate well with the IWGDF’s PEDIS (Perfusion, Extent, Depth, Infection and Sensation) Grades 1, 2, 3, and 4. Wounds are distinguished by size (more or less than 2 cm in width), extent (depth of tissue involvement), and the presence of two or more signs of systemic inflammatory response syndrome.
• Whenever possible, management of DFI should involve multidisciplinary teams that include a microbiologist or ID expert, surgeon/podiatrist familiar with debridement of foot infections, and wound care experts familiar with dressings that provide pressure off-loading.
• All wounds should be debrided, and cultures should be sent from deep tissue via biopsy or curettage (scraping of the base of the ulcer). Wound surface swabs should not be sent for culture, as they often are inaccurate.
• All patients with severe infections and some patients with moderate infections with complicating features (i.e. severe PAD or inability to manage outpatient treatment due to psychosocial reasons) should be admitted. Those with mild infection or some moderate infections without complicating features can be managed as outpatients.
• All patients with suspected DFI should have plain radiographs of the affected limb to evaluate for bony abnormalities, soft-tissue gas, or foreign bodies, but they are only 54% sensitive and 68% specific for osteomyelitis. MRI is more sensitive (90%) and specific (up to 90%) for detecting osteomyelitis. When MRI is contraindicated, a bone scan coupled with a tagged white-blood count scan is the next best test for detecting osteomyelitis.
• Osteomyelitis, which is found in as many as 20% of mild to moderate DFI cases and as many as 50% of severe DFI cases, should be suspected in any patient with large (>2 cm square), deep, or chronic (>six weeks) wounds, as well as those who have wounds overlying a bony prominence or have a positive probe-to-bone (PTB) test. The most definitive diagnosis of osteomyelitis is via bone biopsy for culture and histology. Patients with osteomyelitis can be managed surgically with resection or medically with prolonged antibiotics (>four weeks). If surgical resection removes the infected bone with clean margins, the antibiotic course can be shortened to two to five days post-operatively.
• Effective treatment includes both wound care as well as antibiotic therapy. Antibiotics should be started after cultures are sent. Empiric antibiotics for mild to moderate infections in patients who have not been recently treated can be directed at gram-positive cocci (GPC), as Staphylococcus is the most common causal organism identified. Patients with severe infection can be started empirically on parenteral broad-spectrum antibiotics covering for GPC (particularly methicillin-resistant Staphylococcus aureus in at-risk patients), gram-negative bacteria, and obligate anaerobes. Antibiotics should be tailored once culture and sensitivity results are available. Generally, mild infections should be treated for one to two weeks and moderate to severe infections for two to three weeks, if there is no suspicion of osteomyelitis.

Analysis

The United Kingdom National Institute for Clinical Excellence (NICE) guideline development group published guidelines for inpatient management of diabetic foot problems in 2011.⁶ The NICE guidelines are largely similar to the 2012 IDSA guidelines. NICE guidelines call for each hospital to have a care pathway for all patients who present with a diabetic foot problem, and that these patients should be cared for by a multidisciplinary team, including appropriate wound care and debridement, assessment of vascular function, imaging with plain radiographs and MRI if osteomyelitis is suspected, and directed antibiotic therapy.

HM Takeaways

Diabetic foot infections are a common occurrence, and the guidelines for their management demonstrate how coordinated clinical care is important for improving patient care and outcomes. As health reimbursement moves toward a model of bundled payments for treatment and a greater emphasis on measureable outcomes, hospitalists are well positioned to be managers of such organized approaches with multidisciplinary teams.

Dr. Ly is a hospitalist in the division of hospital medicine at the University of California at San Francisco.

References

1. Centers for Disease Control and Prevention. Age-Adjusted Hospital Discharge Rates for Peripheral Arterial Disease (PAD), Ulcer/Inflammation/Infection (ULCER), or Neuropathy as First-Listed Diagnosis per 1,000 Diabetic Population, United States, 1988–2007. CDC website. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig2_pop.htm. Accessed Jan. 28, 2013.
2. Centers for Disease Control and Prevention. Number (in thousands) of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis, 1988-2006. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig1.htm. Accessed Jan. 28, 2013.
3. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18-25.
4. Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):132-173.
5. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011;342:d1280.

Background

In the U.S. alone, there are an estimated 25.8 million people with diabetes, or about 8.3% of the population. Due to comorbidities of peripheral neuropathy and peripheral vascular disease associated with diabetes, these patients are at higher risk for developing foot infections. Among the myriad diabetes complications, diabetic foot infections (DFI) are the main reason for diabetes-related hospitalizations and lower-extremity amputations. U.S. hospitals admit roughly 5,700 patients per year for DFI; 71,000 lower-extremity amputations are attributed to diabetes.^1,2

Studies have demonstrated that DFI management according to guidelines improves survival, reduces complications, and is cost-effective with a major clinical outcome of reduced amputations.³ But prospective observational studies have shown that, in practice, guidelines often are not followed and can lead to poor outcomes.⁴ Studies suggest a need for more simple, straightforward guidelines.

Guidelines Update

In June 2012, the Infectious Diseases Society of America (IDSA) updated its 2004 guidelines on the management of diabetic foot infections.⁵ Although IDSA made no major changes to its recommendations, the 2012 guidelines were revised to be more simple and clear. These new guidelines have been reviewed and endorsed by SHM.

Specific recommendations include:

• All patients with suspected DFI should be assessed on three levels: the patient, the extremity involved, and the wound. Patients should be assessed for signs of systemic illness or metabolic derangements. The extremity should be examined for peripheral arterial disease (PAD) using the Ankle-Brachial Index (ABI), and those with an ABI <0.4 should be evaluated by a vascular surgeon.
• Uninfected wounds should be distinguished from infected wounds based on the presence of two or more classic signs of inflammation and purulence. All wounds should be classified based on validated systems, such as those established by IDSA or the International Working Group on the Diabetic Foot (IWGDF). The IDSA classification of wounds as uninfected, mild, moderate, and severe correlate well with the IWGDF’s PEDIS (Perfusion, Extent, Depth, Infection and Sensation) Grades 1, 2, 3, and 4. Wounds are distinguished by size (more or less than 2 cm in width), extent (depth of tissue involvement), and the presence of two or more signs of systemic inflammatory response syndrome.
• Whenever possible, management of DFI should involve multidisciplinary teams that include a microbiologist or ID expert, surgeon/podiatrist familiar with debridement of foot infections, and wound care experts familiar with dressings that provide pressure off-loading.
• All wounds should be debrided, and cultures should be sent from deep tissue via biopsy or curettage (scraping of the base of the ulcer). Wound surface swabs should not be sent for culture, as they often are inaccurate.
• All patients with severe infections and some patients with moderate infections with complicating features (i.e. severe PAD or inability to manage outpatient treatment due to psychosocial reasons) should be admitted. Those with mild infection or some moderate infections without complicating features can be managed as outpatients.
• All patients with suspected DFI should have plain radiographs of the affected limb to evaluate for bony abnormalities, soft-tissue gas, or foreign bodies, but they are only 54% sensitive and 68% specific for osteomyelitis. MRI is more sensitive (90%) and specific (up to 90%) for detecting osteomyelitis. When MRI is contraindicated, a bone scan coupled with a tagged white-blood count scan is the next best test for detecting osteomyelitis.
• Osteomyelitis, which is found in as many as 20% of mild to moderate DFI cases and as many as 50% of severe DFI cases, should be suspected in any patient with large (>2 cm square), deep, or chronic (>six weeks) wounds, as well as those who have wounds overlying a bony prominence or have a positive probe-to-bone (PTB) test. The most definitive diagnosis of osteomyelitis is via bone biopsy for culture and histology. Patients with osteomyelitis can be managed surgically with resection or medically with prolonged antibiotics (>four weeks). If surgical resection removes the infected bone with clean margins, the antibiotic course can be shortened to two to five days post-operatively.
• Effective treatment includes both wound care as well as antibiotic therapy. Antibiotics should be started after cultures are sent. Empiric antibiotics for mild to moderate infections in patients who have not been recently treated can be directed at gram-positive cocci (GPC), as Staphylococcus is the most common causal organism identified. Patients with severe infection can be started empirically on parenteral broad-spectrum antibiotics covering for GPC (particularly methicillin-resistant Staphylococcus aureus in at-risk patients), gram-negative bacteria, and obligate anaerobes. Antibiotics should be tailored once culture and sensitivity results are available. Generally, mild infections should be treated for one to two weeks and moderate to severe infections for two to three weeks, if there is no suspicion of osteomyelitis.

Analysis

The United Kingdom National Institute for Clinical Excellence (NICE) guideline development group published guidelines for inpatient management of diabetic foot problems in 2011.⁶ The NICE guidelines are largely similar to the 2012 IDSA guidelines. NICE guidelines call for each hospital to have a care pathway for all patients who present with a diabetic foot problem, and that these patients should be cared for by a multidisciplinary team, including appropriate wound care and debridement, assessment of vascular function, imaging with plain radiographs and MRI if osteomyelitis is suspected, and directed antibiotic therapy.

HM Takeaways

Diabetic foot infections are a common occurrence, and the guidelines for their management demonstrate how coordinated clinical care is important for improving patient care and outcomes. As health reimbursement moves toward a model of bundled payments for treatment and a greater emphasis on measureable outcomes, hospitalists are well positioned to be managers of such organized approaches with multidisciplinary teams.

Dr. Ly is a hospitalist in the division of hospital medicine at the University of California at San Francisco.

References

1. Centers for Disease Control and Prevention. Age-Adjusted Hospital Discharge Rates for Peripheral Arterial Disease (PAD), Ulcer/Inflammation/Infection (ULCER), or Neuropathy as First-Listed Diagnosis per 1,000 Diabetic Population, United States, 1988–2007. CDC website. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig2_pop.htm. Accessed Jan. 28, 2013.
2. Centers for Disease Control and Prevention. Number (in thousands) of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis, 1988-2006. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig1.htm. Accessed Jan. 28, 2013.
3. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18-25.
4. Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):132-173.
5. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011;342:d1280.

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.

Documentation. Physician documentation must include an attestation that supports the physician encounter (e.g. “Patient seen and examined by me”), the individual with whom the service is shared (e.g. “Agree with note by X”), their portion of the rendered service (e.g. “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR”), the date, and a legible signature. NPP documentation should include as similar reference to the physician with whom the service is being shared for better charge capture. It alerts coders, auditors, and payor representatives to consider both notes in support of the billed service and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Although the visit level is supported by both provider services, only one claim may be submitted for a shared/split service. The rendering provider listed on the claim can be the physician (reimbursed at 100% of the Medicare allowable physician rate) or the NPP (reimbursed at 85% of the allowable physician rate).

Non-Medicare Claims

Shared/split billing policy only applies to Medicare beneficiaries, while independent billing policy applies to Medicare and Aetna. Excessive costs prevent most other non-Medicare insurers from credentialing and enrollment NPPs. Absence of payor policy does not disqualify reimbursement for shared services, but it does require additional measures to establish recognition of NPP services and a corresponding reimbursement model.

After determining payor mix, develop a reasonable guideline for those payors who do not enroll NPPs. Delineate, in writing, a predetermined time frame for guideline implementation unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option⁵:

• Type of NPPs involved in patient care;
• Category of services provided;
• Service location(s);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

Guidelines can be developed for any of the billing options (independent, “incident-to,” shared/split). Be sure to obtain written payor response before initiating the billing process.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

NPP Billing Reminders

Discharge Day Management Services

Discharge day management (99238-99239) often is delegated to qualified NPPs.³ Because this service is time-based, the final code selection is based upon the total time spent with the patient, and on the patient’s unit/floor, coordinating care prior to the patient leaving the hospital on the day of discharge. If this service is solely provided by the NPP, the NPP must report the appropriate code under his/her own name on the claim form (for eligible payors). If this service is shared with the physician, report the code representing the cumulative, documented time in both notes, provided that each note identifies the face-toface service from each provider, and his/her corresponding participation.

Admission Services

Many questions arise about NPPs performing the admission service because NPPs might not be given “admitting” privileges by the facility in which they practice. NPPs may provide and/or participate in services according to their state scope practice and facility-imposed guidelines. Billing policy supports state law and will reimburse any “independent” service permitted by the state. Facilities may limit NPP scope of practice by disallowing independent admission service but permittin a shared service with the physician. If this service is shared with the physician, report the code representing the cumulative, documented encounter, provided that each note identifies the face-to-face service from each provider, and his/her corresponding participation

Consultation Services

Prior to Medicare’s elimination of consultation services (99241-99245, 99251-99255), shared/split billing rules excluded consultations from this claim-reporting model.³ Since the elimination of consults, “consultations” are reported as initial hospital care services (99221-99223).³ Therefore, consultative services can be shared by NPPs and physicians, and reported as a cumulative initial hospital service through the shared/ split billing model. Other payors still accept consultation codes and do not have a specified shared/split model. This allows for the consultative service to be reported as a cumulative NPP/physician effort under the physician name, as long as a written contractual agreement exists allowing this billing option.

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed Nov. 5, 2012.
2. Aetna Inc. Aetna office links updates. Reminder: Reimbursement change for mid-level practitioners. Aetna Inc. website. Available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf. Accessed Nov. 6, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 21, 2013.
5. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2011. Northbrook, Ill.: American College of Chest Physicians, 2010.

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.

Documentation. Physician documentation must include an attestation that supports the physician encounter (e.g. “Patient seen and examined by me”), the individual with whom the service is shared (e.g. “Agree with note by X”), their portion of the rendered service (e.g. “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR”), the date, and a legible signature. NPP documentation should include as similar reference to the physician with whom the service is being shared for better charge capture. It alerts coders, auditors, and payor representatives to consider both notes in support of the billed service and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Although the visit level is supported by both provider services, only one claim may be submitted for a shared/split service. The rendering provider listed on the claim can be the physician (reimbursed at 100% of the Medicare allowable physician rate) or the NPP (reimbursed at 85% of the allowable physician rate).

Non-Medicare Claims

Shared/split billing policy only applies to Medicare beneficiaries, while independent billing policy applies to Medicare and Aetna. Excessive costs prevent most other non-Medicare insurers from credentialing and enrollment NPPs. Absence of payor policy does not disqualify reimbursement for shared services, but it does require additional measures to establish recognition of NPP services and a corresponding reimbursement model.

After determining payor mix, develop a reasonable guideline for those payors who do not enroll NPPs. Delineate, in writing, a predetermined time frame for guideline implementation unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option⁵:

• Type of NPPs involved in patient care;
• Category of services provided;
• Service location(s);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

Guidelines can be developed for any of the billing options (independent, “incident-to,” shared/split). Be sure to obtain written payor response before initiating the billing process.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

NPP Billing Reminders

Discharge Day Management Services

Discharge day management (99238-99239) often is delegated to qualified NPPs.³ Because this service is time-based, the final code selection is based upon the total time spent with the patient, and on the patient’s unit/floor, coordinating care prior to the patient leaving the hospital on the day of discharge. If this service is solely provided by the NPP, the NPP must report the appropriate code under his/her own name on the claim form (for eligible payors). If this service is shared with the physician, report the code representing the cumulative, documented time in both notes, provided that each note identifies the face-toface service from each provider, and his/her corresponding participation.

Admission Services

Many questions arise about NPPs performing the admission service because NPPs might not be given “admitting” privileges by the facility in which they practice. NPPs may provide and/or participate in services according to their state scope practice and facility-imposed guidelines. Billing policy supports state law and will reimburse any “independent” service permitted by the state. Facilities may limit NPP scope of practice by disallowing independent admission service but permittin a shared service with the physician. If this service is shared with the physician, report the code representing the cumulative, documented encounter, provided that each note identifies the face-to-face service from each provider, and his/her corresponding participation

Consultation Services

Prior to Medicare’s elimination of consultation services (99241-99245, 99251-99255), shared/split billing rules excluded consultations from this claim-reporting model.³ Since the elimination of consults, “consultations” are reported as initial hospital care services (99221-99223).³ Therefore, consultative services can be shared by NPPs and physicians, and reported as a cumulative initial hospital service through the shared/ split billing model. Other payors still accept consultation codes and do not have a specified shared/split model. This allows for the consultative service to be reported as a cumulative NPP/physician effort under the physician name, as long as a written contractual agreement exists allowing this billing option.

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed Nov. 5, 2012.
2. Aetna Inc. Aetna office links updates. Reminder: Reimbursement change for mid-level practitioners. Aetna Inc. website. Available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf. Accessed Nov. 6, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 21, 2013.
5. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2011. Northbrook, Ill.: American College of Chest Physicians, 2010.

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.

Documentation. Physician documentation must include an attestation that supports the physician encounter (e.g. “Patient seen and examined by me”), the individual with whom the service is shared (e.g. “Agree with note by X”), their portion of the rendered service (e.g. “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR”), the date, and a legible signature. NPP documentation should include as similar reference to the physician with whom the service is being shared for better charge capture. It alerts coders, auditors, and payor representatives to consider both notes in support of the billed service and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Although the visit level is supported by both provider services, only one claim may be submitted for a shared/split service. The rendering provider listed on the claim can be the physician (reimbursed at 100% of the Medicare allowable physician rate) or the NPP (reimbursed at 85% of the allowable physician rate).

Non-Medicare Claims

Shared/split billing policy only applies to Medicare beneficiaries, while independent billing policy applies to Medicare and Aetna. Excessive costs prevent most other non-Medicare insurers from credentialing and enrollment NPPs. Absence of payor policy does not disqualify reimbursement for shared services, but it does require additional measures to establish recognition of NPP services and a corresponding reimbursement model.

After determining payor mix, develop a reasonable guideline for those payors who do not enroll NPPs. Delineate, in writing, a predetermined time frame for guideline implementation unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option⁵:

• Type of NPPs involved in patient care;
• Category of services provided;
• Service location(s);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

Guidelines can be developed for any of the billing options (independent, “incident-to,” shared/split). Be sure to obtain written payor response before initiating the billing process.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

NPP Billing Reminders

Discharge Day Management Services

Discharge day management (99238-99239) often is delegated to qualified NPPs.³ Because this service is time-based, the final code selection is based upon the total time spent with the patient, and on the patient’s unit/floor, coordinating care prior to the patient leaving the hospital on the day of discharge. If this service is solely provided by the NPP, the NPP must report the appropriate code under his/her own name on the claim form (for eligible payors). If this service is shared with the physician, report the code representing the cumulative, documented time in both notes, provided that each note identifies the face-toface service from each provider, and his/her corresponding participation.

Admission Services

Many questions arise about NPPs performing the admission service because NPPs might not be given “admitting” privileges by the facility in which they practice. NPPs may provide and/or participate in services according to their state scope practice and facility-imposed guidelines. Billing policy supports state law and will reimburse any “independent” service permitted by the state. Facilities may limit NPP scope of practice by disallowing independent admission service but permittin a shared service with the physician. If this service is shared with the physician, report the code representing the cumulative, documented encounter, provided that each note identifies the face-to-face service from each provider, and his/her corresponding participation

Consultation Services

Prior to Medicare’s elimination of consultation services (99241-99245, 99251-99255), shared/split billing rules excluded consultations from this claim-reporting model.³ Since the elimination of consults, “consultations” are reported as initial hospital care services (99221-99223).³ Therefore, consultative services can be shared by NPPs and physicians, and reported as a cumulative initial hospital service through the shared/ split billing model. Other payors still accept consultation codes and do not have a specified shared/split model. This allows for the consultative service to be reported as a cumulative NPP/physician effort under the physician name, as long as a written contractual agreement exists allowing this billing option.

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed Nov. 5, 2012.
2. Aetna Inc. Aetna office links updates. Reminder: Reimbursement change for mid-level practitioners. Aetna Inc. website. Available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf. Accessed Nov. 6, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 21, 2013.
5. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2011. Northbrook, Ill.: American College of Chest Physicians, 2010.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Guidelines on steroids and antivirals to treat Bell’s palsy
2. Probiotics to reduce Clostridium difficile-associated diarrhea
3. Rates of hemorrhage from warfarin therapy higher in clinical practice
4. Less experienced doctors incur higher treatment costs
5. Pay-for-performance incentive reduces mortality in England
6. No benefit in ultrafiltration to treat acute heart failure
7. Hospitalized patients often receive too much acetaminophen
8. Longer anticoagulation therapy beneficial after bioprosthetic aortic valve replacement
9. Antimicrobial-coated catheters and risk of urinary tract infection
10. Patient outcomes improve after in-hospital cardiac arrest

Updated Guidelines on Steroids and Antivirals in Bell’s Palsy

Clinical question: Does the use of steroids and/or antivirals improve recovery in patients with newly diagnosed Bell’s palsy?

Background: The American Academy of Neurology’s last recommendation in 2001 stated that steroids were probably effective and antivirals possibly effective. The current review and recommendations looked at additional studies published since 2000.

Study design: Systematic review of MEDLINE and Cochrane Database of Systematic Reviews data published since June 2000.

Setting: Prospective controlled studies from Germany, Sweden, Scotland, Italy, South Korea, Japan, and Bangladesh.

Synopsis: The authors identified nine studies that fulfilled inclusion criteria. Two of these studies examined treatment with steroids alone and were judged to have the lowest risk for bias. Both studies enrolled patients within three days of symptom onset, continued treatment for 10 days, and demonstrated a significant increase in the probability of complete recovery in patients randomized to steroids (NNT 6-8). Two high-quality studies were identified that looked at the addition of antivirals to steroids. Neither study showed a statistically significant benefit.

Of note, the studies did not quantify the risk of harm from steroid use in patients with comorbidities, such as diabetes. Thus, the authors concluded that in some patients, it would be reasonable to consider limiting steroid use.

Bottom line: For patients with new-onset Bell’s palsy, steroids increase the probability of recovery of facial nerve function. Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is modest at best.

Citation: Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012;79(22):2209-2213.

Probiotic Prophylaxis Reduces Clostridium Difficile-Associated Diarrhea

Clinical question: Are probiotics a safe and efficacious therapy for the prevention of Clostridium difficile-associated diarrhea (CDAD)?

Background: CDAD is the most common cause of hospital-acquired infectious diarrhea in high-income countries. There has been a dramatic rise in the incidence and severity of CDAD since 2002. Previous studies suggested that probiotics might reduce the incidence of CDAD with few adverse events.

Study design: Systematic review and meta-analysis of the literature.

Setting: Randomized controlled trials from the U.S., Canada, Chile, China, United Kingdom, Turkey, Poland, and Sweden.

Synopsis: Investigators identified 20 trials including 3,818 participants using a systematic search of randomized controlled trials of a specified probiotic of any strain in adults or pediatric subjects treated with antibiotics. Probiotics reduced the incidence of CDAD by 66% (risk ratio 0.34, 95% CI 0.24 to 0.49). Subgroup analyses showed similar results in both adults and children, with lower and high doses, and with different probiotic species.

Of probiotic-treated patients, 9.3% experienced an adverse event compared with 12.6% of control patients (relative risk 0.82, 95% CI 0.65 to 1.05). There was no report of any serious adverse events attributable to probiotics.

One limitation is the considerable variability in the reported risk of CDAD in the control group (0% to 40%). The absolute benefit from probiotics will depend on the risk in patients who do not receive prophylaxis.

Bottom line: Moderate-quality evidence suggests that probiotic prophylaxis results in a large reduction in C. diff-associated diarrhea without an increase in clinically important adverse events.

Citation: Johnston BC, Ma SSY, Goldenberg JZ, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):878-888.

Rates of Hemorrhage from Warfarin Therapy Higher in Clinical Practice

Clinical question: What is the incidence of hemorrhage in a large population-based cohort of patients with atrial fibrillation who have started warfarin therapy?

Background: There is strong evidence that supports the use of warfarin to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. There are currently no large studies offering real-world, population-based estimates of hemorrhage rates among patients taking warfarin.

Study design: Retrospective cohort study.

Setting: Ontario.

Synopsis: This population-based, cohort study included 125,195 residents of Ontario age ≥66 years with atrial fibrillation who started taking warfarin sometime from 1997 to 2008. Hemorrhage was defined as bleeding requiring an emergency department visit or hospital admission. The overall risk of hemorrhage was 3.8% per person-year, but it was 11.8% in the first 30 days of therapy. For subjects age >75 years, the overall risk was 4.6% compared with 2.9% for those between 66 and 75 years.

Most hospital admissions involved gastrointestinal hemorrhages (63%). Almost 1 in 5 people (18%) with hospital admissions for hemorrhages died in the hospital or within seven days of discharge.

Bottom line: Rates of hemorrhage for older patients on warfarin therapy are significantly higher in clinical practice than the rates reported in clinical trials. The difference is likely due to the strict inclusion criteria, younger average age, and close monitoring of patients in clinical trials.

Citation: Gomes T, Mamdani MM, Holbrook AM, Paterson JM, Hellings C, Juurlink DN. Rates of hemorrhage during warfarin therapy for atrial fibrillation. CMAJ. 2013; Jan 21 [Epub ahead of print].

Less Experienced Doctors Incur Higher Treatment Costs

Clinical question: Which physician characteristics are associated with higher cost profiles?

Background: While both public and private insurers increasingly use physician cost profiles to identify physicians whose practice patterns account for more healthcare spending than other physicians, the individual physician characteristics associated with cost-profile performance are unknown.

Study design: Retrospective cohort study.

Setting: Four commercial health plans in Massachusetts.

Synopsis: Data collected from the insurance claims records of 1.13 million patients aged 18-65 years who were enrolled in one of four commercial health plans in Massachusetts in 2004 and 2005 were matched with the public records of 12,116 doctors who were stratified into five groups according to years of experience (<10, 10-19, 20-29, 30-39, and ≥40 years).

A strong association was found between physician experience and cost profiles, with the most experienced doctors—40 or more years of experience—providing the least costly care. Costs increased with each successively less experienced group (by 2.5%, 6.5%, 10%, and 13.2% more, respectively, to treat the same condition). No association was found between cost profiles and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and practice size.

Differences appear to be driven by high-cost outlier patients. While median costs were similar between physicians with different levels of experience, the costs of treating patients at the 95 percentile of cost were much higher among physicians with less experience.

Bottom line: Doctors in this study with the least experience incurred 13.2% greater costs than their most senior counterparts.

Citation: Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463.

Pay-For-Performance Incentive Reduces Mortality in England

Clinical question: Do pay-for-performance programs improve quality of care?

Background: Pay-for-performance programs are being widely adopted both internationally and in the U.S. There is, however, limited evidence that these programs improve patient outcomes, and most prior studies have shown modest or inconsistent improvements in quality of care.

Study design: Prospective cohort study.

Setting: National Health Service (NHS) hospitals in northwest England.

Synopsis: The Advanced Quality program, the first hospital-based pay-for-performance program in England, was introduced in October 2004 in all 24 NHS hospitals in northwest England that provide emergency care. The program used a “tournament” system in which only the top-performing hospitals received bonus payments. There was no penalty for poor performers.

The primary end-point was 30-day in-hospital mortality among patients admitted for pneumonia, heart failure, or acute myocardial infarction. Over the three-year period studied (18 months before and 18 months after introduction of the program), the risk-adjusted mortality for these three conditions decreased significantly with an absolute reduction of 1.3% (95% CI 0.4 to 2.1%; P=0.006). The largest change, for pneumonia, was significant (1.9%, 95% CI 0.9 to 3.0, P<0.001), with nonsignificant reductions for acute myocardial infarction (0.6%, 95% CI -0.4 to 1.7; P=0.23) and heart failure (0.6%, 95% CI -0.6 to 1.8; P=0.30).

Bottom line: The introduction of a pay-for-performance program for all National Health Service hospitals in one region of England was associated with a significant reduction in mortality.

Citation: Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. Reduced mortality with hospital pay for performance in England. N Engl J Med. 2012;367(19):1821-1828.

Ultrafiltration Shows No Benefit in Acute Heart Failure

Clinical question: Is ultrafiltration superior to pharmacotherapy in the treatment of patients with acute heart failure and cardiorenal syndrome?

Background: Venovenous ultrafiltration is an alternative to diuretic therapy in patients with acute decompensated heart failure and worsened renal function that could allow greater control of the rate of fluid removal and improve outcomes. Little is known about the efficacy and safety of ultrafiltration compared to standard pharmacological therapy.

Study design: Multicenter randomized controlled trial.

Setting: Fourteen clinical centers in the U.S. and Canada.

Synopsis: One hundred eighty-eight patients admitted to a hospital with acute decompensated heart failure and worsened renal function were randomized to stepped pharmacological therapy or ultrafiltration. Ultrafiltration was inferior to pharmacological therapy with respect to the pre-specified primary composite endpoint, the change in serum creatinine level, and body weight at 96 hours after enrollment (P=0.003). This difference was primarily due to an increase in the serum creatinine level in the ultrafiltration group (0.23 vs. -0.04 mg/dl; P=0.003). There was no significant difference in weight loss at 96 hours (loss of 5.5 kg vs. 5.7kg; P=0.58).

A higher percentage of patients in the ultrafiltration group had a serious adverse event over the 60-day follow-up period (72% vs. 57%, P=0.03). There was no significant difference in the composite rate of death or rehospitalization for heart failure in the ultrafiltration group compared to the pharmacologic-therapy group (38% vs. 35%; P=0.96).

Bottom line: Pharmacological therapy is superior to ultrafiltration in patients with acute decompensated heart failure and worsened renal function.

Citation: Bart BA, Goldsmith SR, Lee KL, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367:2296-2304.

Hospitalized Patients Often Receive Too Much Acetaminophen

Clinical question: What are the prevalence and factors associated with supratherapeutic dosing of acetaminophen in hospitalized patients?

Background: Acetaminophen is a commonly used medication that at high doses can be associated with significant adverse events, including liver failure. Considerable efforts have been made in the outpatient setting to limit the risks associated with acetaminophen. Little research has examined acetaminophen exposure in the inpatient setting.

Study design: Retrospective cohort study.

Setting: Two academic tertiary-care hospitals in the U.S.

Synopsis: The authors reviewed the electronic medication administration record of all adult patients admitted to two academic hospitals from June 1, 2010, to Aug. 31, 2010. A total of 14,411 patients (60.7%) were prescribed acetaminophen, of whom 955 (6.6%) were prescribed more than the 4g per day (the maximum recommended daily dose) at least once. In addition, 22.3% of patients >65 and 17.6% of patients with chronic liver disease exceeded the recommended limit of 3g per day. Half the supratherapeutic episodes involved doses exceeding 5g a day, often for several days. In adjusted analyses, scheduled administration (rather than as needed), a diagnosis of osteoarthritis, and higher-strength tablets were all associated with a higher risk of exposure to supratherapeutic doses.

Bottom line: A significant proportion of hospitalized patients are exposed to supratherapeutic dosing of acetaminophen.

Citation: Zhou L, Maviglia SM, Mahoney LM, et al. Supra-therapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012;172(22):1721-1728.

Longer Anticoagulation Therapy after Bioprosthetic Aortic Valve Replacement Might Be Beneficial

Clinical question: How long should anticoagulation therapy with warfarin be continued after surgical bioprosthetic aortic valve replacement?

Background: Current guidelines recommend a three-month course of anticoagulation therapy after bioprosthetic aortic valve surgery. However, the appropriate duration of post-operative anticoagulation therapy has not been well established

Study design: Retrospective cohort study.

Setting: Denmark.

Synopsis: Using data from the Danish National Registries, 4,075 subjects without atrial fibrillation who underwent bioprosthetic aortic valve implantation from 1997 to 2009 were identified. The association between different durations of warfarin therapy after aortic valve implantation and the combined end point of stroke, thromboembolic events, cardiovascular death, or bleeding episodes was examined.

The risk of adverse outcomes was substantially higher for patients not treated with warfarin compared to treated patents. The estimated adverse event rate was 7 per 100 person-years for untreated patients versus 2.7 per 100 for warfarin-treated patients (adjusted incidence rate ratio [IRR] 2.46, 95% CI 1.09 to 6.48). Patients not treated with warfarin were at higher risk of cardiovascular death within 30 to 89 days after surgery, with an event rate of 31.7 per 100 person-years versus 3.8 per 100 person-years (adjusted IRR 7.61, 95% CI 4.37 to 13.26). The difference in cardiovascular mortality continued to be significant from 90 to 179 days after surgery, with an event rate of 6.5 per 100 person-years versus 2.1 per 100 person-years (IRR 3.51, 95% CI 1.54 to 8.03).

Bottom line: Discontinuation of warfarin therapy within six months of bioprosthetic aortic valve replacement is associated with increased cardiovascular death.

Citation: Mérie C, Køber L, Skov Olsen P, et al. Association of warfarin therapy duration after bioprosthetic aortic valve replacement with risk of mortality, thromboembolic complications, and bleeding. JAMA. 2012;308(20):2118-2125.

Limited Evidence for Antimicrobial-Coated Catheters

Clinical question: Does the use of antimicrobial-coated catheters reduce the risk of catheter-associated urinary tract infection (UTI) compared to standard polytetrafluoroethylene (PTFE) catheters?

Background: UTIs associated with indwelling catheters are a major preventable cause of harm for hospitalized patients. Prior studies have shown that catheters made with antimicrobial coatings can reduce rates of bacteriuria, but their usefulness against symptomatic catheter-associated UTIs remains uncertain.

Study design: Multicenter randomized controlled trial.

Setting: Twenty-four hospitals in the United Kingdom.

Synopsis: A total of 7,102 patients >16 undergoing urethral catheterization for an anticipated duration of <14 days were randomly allocated in a 1:1:1 ratio to receive a silver-alloy-coated catheter, a nitrofural-impregnated silicone catheter, or a standard PTFE-coated catheter. The primary outcome was defined as presence of patient-reported symptoms of UTI and prescription of antibiotic for UTI. Incidence of symptomatic catheter-associated UTI up to six weeks after randomization did not differ significantly between groups and occurred in 12.6% of the PTFE control, 12.5% of the silver alloy group, and 10.6% of the nitrofural group. In secondary outcomes, the nitrofural catheter was associated with a slightly reduced incidence of culture-confirmed symptomatic UTI (absolute risk reduction of 1.4%) and lower rate of bacteriuria, but it also had greater patient-reported discomfort during use and removal.

Bottom line: Antimicrobial-coated catheters do not show a clinically significant benefit over standard PTFE catheters in preventing catheter-associated UTI.

Citation: Pickard R, Lam T, Maclennan G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomized controlled trial. Lancet. 2012;380:1927-1935.

Outcomes Improve after In-Hospital Cardiac Arrest

Clinical question: Have outcomes after in-hospital cardiac arrest improved with recent advances in resuscitation care?

Background: Over the past decade, quality-improvement (QI) efforts in hospital resuscitation care have included use of mock cardiac arrests, defibrillation by nonmedical personnel, and participation in QI registries. It is unclear what effect these efforts have had on overall survival and neurologic recovery.

Study design: Retrospective cohort study.

Setting: Five hundred fifty-three hospitals in the U.S.

Synopsis: A total of 113,514 patients age >18 with a cardiac arrest occurring from Jan. 1, 2000, to Nov. 19, 2009, were identified. Analyses were separated by initial rhythm (PEA/asystole or ventricular fibrillation/tachycardia). Overall survival to discharge increased significantly to 22.3% in 2009 from 13.7% in 2000, with similar increases within each rhythm group. Rates of acute resuscitation survival (return of spontaneous circulation for at least 20 contiguous minutes after initial arrest) and post-resuscitation survival (survival to discharge among patients surviving acute resuscitation) also improved during the study period. Rates of clinically significant neurologic disability, as defined by cerebral performance scores >1, decreased over time for the overall cohort and the subset with ventricular fibrillation/tachycardia. The study was limited by including only hospitals motivated to participate in a QI registry.

Bottom line: From 2000 to 2009, survival after in-hospital cardiac arrest improved, and rates of clinically significant neurologic disability among survivors decreased.

Citation: Girotra S, Nallamothu B, Spertus J, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367:1912-1920.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Guidelines on steroids and antivirals to treat Bell’s palsy
2. Probiotics to reduce Clostridium difficile-associated diarrhea
3. Rates of hemorrhage from warfarin therapy higher in clinical practice
4. Less experienced doctors incur higher treatment costs
5. Pay-for-performance incentive reduces mortality in England
6. No benefit in ultrafiltration to treat acute heart failure
7. Hospitalized patients often receive too much acetaminophen
8. Longer anticoagulation therapy beneficial after bioprosthetic aortic valve replacement
9. Antimicrobial-coated catheters and risk of urinary tract infection
10. Patient outcomes improve after in-hospital cardiac arrest

Updated Guidelines on Steroids and Antivirals in Bell’s Palsy

Clinical question: Does the use of steroids and/or antivirals improve recovery in patients with newly diagnosed Bell’s palsy?

Background: The American Academy of Neurology’s last recommendation in 2001 stated that steroids were probably effective and antivirals possibly effective. The current review and recommendations looked at additional studies published since 2000.

Study design: Systematic review of MEDLINE and Cochrane Database of Systematic Reviews data published since June 2000.

Setting: Prospective controlled studies from Germany, Sweden, Scotland, Italy, South Korea, Japan, and Bangladesh.

Synopsis: The authors identified nine studies that fulfilled inclusion criteria. Two of these studies examined treatment with steroids alone and were judged to have the lowest risk for bias. Both studies enrolled patients within three days of symptom onset, continued treatment for 10 days, and demonstrated a significant increase in the probability of complete recovery in patients randomized to steroids (NNT 6-8). Two high-quality studies were identified that looked at the addition of antivirals to steroids. Neither study showed a statistically significant benefit.

Of note, the studies did not quantify the risk of harm from steroid use in patients with comorbidities, such as diabetes. Thus, the authors concluded that in some patients, it would be reasonable to consider limiting steroid use.

Bottom line: For patients with new-onset Bell’s palsy, steroids increase the probability of recovery of facial nerve function. Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is modest at best.

Citation: Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012;79(22):2209-2213.

Probiotic Prophylaxis Reduces Clostridium Difficile-Associated Diarrhea

Clinical question: Are probiotics a safe and efficacious therapy for the prevention of Clostridium difficile-associated diarrhea (CDAD)?

Background: CDAD is the most common cause of hospital-acquired infectious diarrhea in high-income countries. There has been a dramatic rise in the incidence and severity of CDAD since 2002. Previous studies suggested that probiotics might reduce the incidence of CDAD with few adverse events.

Study design: Systematic review and meta-analysis of the literature.

Setting: Randomized controlled trials from the U.S., Canada, Chile, China, United Kingdom, Turkey, Poland, and Sweden.

Synopsis: Investigators identified 20 trials including 3,818 participants using a systematic search of randomized controlled trials of a specified probiotic of any strain in adults or pediatric subjects treated with antibiotics. Probiotics reduced the incidence of CDAD by 66% (risk ratio 0.34, 95% CI 0.24 to 0.49). Subgroup analyses showed similar results in both adults and children, with lower and high doses, and with different probiotic species.

Of probiotic-treated patients, 9.3% experienced an adverse event compared with 12.6% of control patients (relative risk 0.82, 95% CI 0.65 to 1.05). There was no report of any serious adverse events attributable to probiotics.

One limitation is the considerable variability in the reported risk of CDAD in the control group (0% to 40%). The absolute benefit from probiotics will depend on the risk in patients who do not receive prophylaxis.

Bottom line: Moderate-quality evidence suggests that probiotic prophylaxis results in a large reduction in C. diff-associated diarrhea without an increase in clinically important adverse events.

Citation: Johnston BC, Ma SSY, Goldenberg JZ, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):878-888.

Rates of Hemorrhage from Warfarin Therapy Higher in Clinical Practice

Clinical question: What is the incidence of hemorrhage in a large population-based cohort of patients with atrial fibrillation who have started warfarin therapy?

Background: There is strong evidence that supports the use of warfarin to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. There are currently no large studies offering real-world, population-based estimates of hemorrhage rates among patients taking warfarin.

Study design: Retrospective cohort study.

Setting: Ontario.

Synopsis: This population-based, cohort study included 125,195 residents of Ontario age ≥66 years with atrial fibrillation who started taking warfarin sometime from 1997 to 2008. Hemorrhage was defined as bleeding requiring an emergency department visit or hospital admission. The overall risk of hemorrhage was 3.8% per person-year, but it was 11.8% in the first 30 days of therapy. For subjects age >75 years, the overall risk was 4.6% compared with 2.9% for those between 66 and 75 years.

Most hospital admissions involved gastrointestinal hemorrhages (63%). Almost 1 in 5 people (18%) with hospital admissions for hemorrhages died in the hospital or within seven days of discharge.

Bottom line: Rates of hemorrhage for older patients on warfarin therapy are significantly higher in clinical practice than the rates reported in clinical trials. The difference is likely due to the strict inclusion criteria, younger average age, and close monitoring of patients in clinical trials.

Citation: Gomes T, Mamdani MM, Holbrook AM, Paterson JM, Hellings C, Juurlink DN. Rates of hemorrhage during warfarin therapy for atrial fibrillation. CMAJ. 2013; Jan 21 [Epub ahead of print].

Less Experienced Doctors Incur Higher Treatment Costs

Clinical question: Which physician characteristics are associated with higher cost profiles?

Background: While both public and private insurers increasingly use physician cost profiles to identify physicians whose practice patterns account for more healthcare spending than other physicians, the individual physician characteristics associated with cost-profile performance are unknown.

Study design: Retrospective cohort study.

Setting: Four commercial health plans in Massachusetts.

Synopsis: Data collected from the insurance claims records of 1.13 million patients aged 18-65 years who were enrolled in one of four commercial health plans in Massachusetts in 2004 and 2005 were matched with the public records of 12,116 doctors who were stratified into five groups according to years of experience (<10, 10-19, 20-29, 30-39, and ≥40 years).

A strong association was found between physician experience and cost profiles, with the most experienced doctors—40 or more years of experience—providing the least costly care. Costs increased with each successively less experienced group (by 2.5%, 6.5%, 10%, and 13.2% more, respectively, to treat the same condition). No association was found between cost profiles and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and practice size.

Differences appear to be driven by high-cost outlier patients. While median costs were similar between physicians with different levels of experience, the costs of treating patients at the 95 percentile of cost were much higher among physicians with less experience.

Bottom line: Doctors in this study with the least experience incurred 13.2% greater costs than their most senior counterparts.

Citation: Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463.

Pay-For-Performance Incentive Reduces Mortality in England

Clinical question: Do pay-for-performance programs improve quality of care?

Background: Pay-for-performance programs are being widely adopted both internationally and in the U.S. There is, however, limited evidence that these programs improve patient outcomes, and most prior studies have shown modest or inconsistent improvements in quality of care.

Study design: Prospective cohort study.

Setting: National Health Service (NHS) hospitals in northwest England.

Synopsis: The Advanced Quality program, the first hospital-based pay-for-performance program in England, was introduced in October 2004 in all 24 NHS hospitals in northwest England that provide emergency care. The program used a “tournament” system in which only the top-performing hospitals received bonus payments. There was no penalty for poor performers.

The primary end-point was 30-day in-hospital mortality among patients admitted for pneumonia, heart failure, or acute myocardial infarction. Over the three-year period studied (18 months before and 18 months after introduction of the program), the risk-adjusted mortality for these three conditions decreased significantly with an absolute reduction of 1.3% (95% CI 0.4 to 2.1%; P=0.006). The largest change, for pneumonia, was significant (1.9%, 95% CI 0.9 to 3.0, P<0.001), with nonsignificant reductions for acute myocardial infarction (0.6%, 95% CI -0.4 to 1.7; P=0.23) and heart failure (0.6%, 95% CI -0.6 to 1.8; P=0.30).

Bottom line: The introduction of a pay-for-performance program for all National Health Service hospitals in one region of England was associated with a significant reduction in mortality.

Citation: Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. Reduced mortality with hospital pay for performance in England. N Engl J Med. 2012;367(19):1821-1828.

Ultrafiltration Shows No Benefit in Acute Heart Failure

Clinical question: Is ultrafiltration superior to pharmacotherapy in the treatment of patients with acute heart failure and cardiorenal syndrome?

Background: Venovenous ultrafiltration is an alternative to diuretic therapy in patients with acute decompensated heart failure and worsened renal function that could allow greater control of the rate of fluid removal and improve outcomes. Little is known about the efficacy and safety of ultrafiltration compared to standard pharmacological therapy.

Study design: Multicenter randomized controlled trial.

Setting: Fourteen clinical centers in the U.S. and Canada.

Synopsis: One hundred eighty-eight patients admitted to a hospital with acute decompensated heart failure and worsened renal function were randomized to stepped pharmacological therapy or ultrafiltration. Ultrafiltration was inferior to pharmacological therapy with respect to the pre-specified primary composite endpoint, the change in serum creatinine level, and body weight at 96 hours after enrollment (P=0.003). This difference was primarily due to an increase in the serum creatinine level in the ultrafiltration group (0.23 vs. -0.04 mg/dl; P=0.003). There was no significant difference in weight loss at 96 hours (loss of 5.5 kg vs. 5.7kg; P=0.58).

A higher percentage of patients in the ultrafiltration group had a serious adverse event over the 60-day follow-up period (72% vs. 57%, P=0.03). There was no significant difference in the composite rate of death or rehospitalization for heart failure in the ultrafiltration group compared to the pharmacologic-therapy group (38% vs. 35%; P=0.96).

Bottom line: Pharmacological therapy is superior to ultrafiltration in patients with acute decompensated heart failure and worsened renal function.

Citation: Bart BA, Goldsmith SR, Lee KL, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367:2296-2304.

Hospitalized Patients Often Receive Too Much Acetaminophen

Clinical question: What are the prevalence and factors associated with supratherapeutic dosing of acetaminophen in hospitalized patients?

Background: Acetaminophen is a commonly used medication that at high doses can be associated with significant adverse events, including liver failure. Considerable efforts have been made in the outpatient setting to limit the risks associated with acetaminophen. Little research has examined acetaminophen exposure in the inpatient setting.

Study design: Retrospective cohort study.

Setting: Two academic tertiary-care hospitals in the U.S.

Synopsis: The authors reviewed the electronic medication administration record of all adult patients admitted to two academic hospitals from June 1, 2010, to Aug. 31, 2010. A total of 14,411 patients (60.7%) were prescribed acetaminophen, of whom 955 (6.6%) were prescribed more than the 4g per day (the maximum recommended daily dose) at least once. In addition, 22.3% of patients >65 and 17.6% of patients with chronic liver disease exceeded the recommended limit of 3g per day. Half the supratherapeutic episodes involved doses exceeding 5g a day, often for several days. In adjusted analyses, scheduled administration (rather than as needed), a diagnosis of osteoarthritis, and higher-strength tablets were all associated with a higher risk of exposure to supratherapeutic doses.

Bottom line: A significant proportion of hospitalized patients are exposed to supratherapeutic dosing of acetaminophen.

Citation: Zhou L, Maviglia SM, Mahoney LM, et al. Supra-therapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012;172(22):1721-1728.

Longer Anticoagulation Therapy after Bioprosthetic Aortic Valve Replacement Might Be Beneficial

Clinical question: How long should anticoagulation therapy with warfarin be continued after surgical bioprosthetic aortic valve replacement?

Background: Current guidelines recommend a three-month course of anticoagulation therapy after bioprosthetic aortic valve surgery. However, the appropriate duration of post-operative anticoagulation therapy has not been well established

Study design: Retrospective cohort study.

Setting: Denmark.

Synopsis: Using data from the Danish National Registries, 4,075 subjects without atrial fibrillation who underwent bioprosthetic aortic valve implantation from 1997 to 2009 were identified. The association between different durations of warfarin therapy after aortic valve implantation and the combined end point of stroke, thromboembolic events, cardiovascular death, or bleeding episodes was examined.

The risk of adverse outcomes was substantially higher for patients not treated with warfarin compared to treated patents. The estimated adverse event rate was 7 per 100 person-years for untreated patients versus 2.7 per 100 for warfarin-treated patients (adjusted incidence rate ratio [IRR] 2.46, 95% CI 1.09 to 6.48). Patients not treated with warfarin were at higher risk of cardiovascular death within 30 to 89 days after surgery, with an event rate of 31.7 per 100 person-years versus 3.8 per 100 person-years (adjusted IRR 7.61, 95% CI 4.37 to 13.26). The difference in cardiovascular mortality continued to be significant from 90 to 179 days after surgery, with an event rate of 6.5 per 100 person-years versus 2.1 per 100 person-years (IRR 3.51, 95% CI 1.54 to 8.03).

Bottom line: Discontinuation of warfarin therapy within six months of bioprosthetic aortic valve replacement is associated with increased cardiovascular death.

Citation: Mérie C, Køber L, Skov Olsen P, et al. Association of warfarin therapy duration after bioprosthetic aortic valve replacement with risk of mortality, thromboembolic complications, and bleeding. JAMA. 2012;308(20):2118-2125.

Limited Evidence for Antimicrobial-Coated Catheters

Clinical question: Does the use of antimicrobial-coated catheters reduce the risk of catheter-associated urinary tract infection (UTI) compared to standard polytetrafluoroethylene (PTFE) catheters?

Background: UTIs associated with indwelling catheters are a major preventable cause of harm for hospitalized patients. Prior studies have shown that catheters made with antimicrobial coatings can reduce rates of bacteriuria, but their usefulness against symptomatic catheter-associated UTIs remains uncertain.

Study design: Multicenter randomized controlled trial.

Setting: Twenty-four hospitals in the United Kingdom.

Synopsis: A total of 7,102 patients >16 undergoing urethral catheterization for an anticipated duration of <14 days were randomly allocated in a 1:1:1 ratio to receive a silver-alloy-coated catheter, a nitrofural-impregnated silicone catheter, or a standard PTFE-coated catheter. The primary outcome was defined as presence of patient-reported symptoms of UTI and prescription of antibiotic for UTI. Incidence of symptomatic catheter-associated UTI up to six weeks after randomization did not differ significantly between groups and occurred in 12.6% of the PTFE control, 12.5% of the silver alloy group, and 10.6% of the nitrofural group. In secondary outcomes, the nitrofural catheter was associated with a slightly reduced incidence of culture-confirmed symptomatic UTI (absolute risk reduction of 1.4%) and lower rate of bacteriuria, but it also had greater patient-reported discomfort during use and removal.

Bottom line: Antimicrobial-coated catheters do not show a clinically significant benefit over standard PTFE catheters in preventing catheter-associated UTI.

Citation: Pickard R, Lam T, Maclennan G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomized controlled trial. Lancet. 2012;380:1927-1935.

Outcomes Improve after In-Hospital Cardiac Arrest

Clinical question: Have outcomes after in-hospital cardiac arrest improved with recent advances in resuscitation care?

Background: Over the past decade, quality-improvement (QI) efforts in hospital resuscitation care have included use of mock cardiac arrests, defibrillation by nonmedical personnel, and participation in QI registries. It is unclear what effect these efforts have had on overall survival and neurologic recovery.

Study design: Retrospective cohort study.

Setting: Five hundred fifty-three hospitals in the U.S.

Synopsis: A total of 113,514 patients age >18 with a cardiac arrest occurring from Jan. 1, 2000, to Nov. 19, 2009, were identified. Analyses were separated by initial rhythm (PEA/asystole or ventricular fibrillation/tachycardia). Overall survival to discharge increased significantly to 22.3% in 2009 from 13.7% in 2000, with similar increases within each rhythm group. Rates of acute resuscitation survival (return of spontaneous circulation for at least 20 contiguous minutes after initial arrest) and post-resuscitation survival (survival to discharge among patients surviving acute resuscitation) also improved during the study period. Rates of clinically significant neurologic disability, as defined by cerebral performance scores >1, decreased over time for the overall cohort and the subset with ventricular fibrillation/tachycardia. The study was limited by including only hospitals motivated to participate in a QI registry.

Bottom line: From 2000 to 2009, survival after in-hospital cardiac arrest improved, and rates of clinically significant neurologic disability among survivors decreased.

Citation: Girotra S, Nallamothu B, Spertus J, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367:1912-1920.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Guidelines on steroids and antivirals to treat Bell’s palsy
2. Probiotics to reduce Clostridium difficile-associated diarrhea
3. Rates of hemorrhage from warfarin therapy higher in clinical practice
4. Less experienced doctors incur higher treatment costs
5. Pay-for-performance incentive reduces mortality in England
6. No benefit in ultrafiltration to treat acute heart failure
7. Hospitalized patients often receive too much acetaminophen
8. Longer anticoagulation therapy beneficial after bioprosthetic aortic valve replacement
9. Antimicrobial-coated catheters and risk of urinary tract infection
10. Patient outcomes improve after in-hospital cardiac arrest

Updated Guidelines on Steroids and Antivirals in Bell’s Palsy

Clinical question: Does the use of steroids and/or antivirals improve recovery in patients with newly diagnosed Bell’s palsy?

Background: The American Academy of Neurology’s last recommendation in 2001 stated that steroids were probably effective and antivirals possibly effective. The current review and recommendations looked at additional studies published since 2000.

Study design: Systematic review of MEDLINE and Cochrane Database of Systematic Reviews data published since June 2000.

Setting: Prospective controlled studies from Germany, Sweden, Scotland, Italy, South Korea, Japan, and Bangladesh.

Synopsis: The authors identified nine studies that fulfilled inclusion criteria. Two of these studies examined treatment with steroids alone and were judged to have the lowest risk for bias. Both studies enrolled patients within three days of symptom onset, continued treatment for 10 days, and demonstrated a significant increase in the probability of complete recovery in patients randomized to steroids (NNT 6-8). Two high-quality studies were identified that looked at the addition of antivirals to steroids. Neither study showed a statistically significant benefit.

Of note, the studies did not quantify the risk of harm from steroid use in patients with comorbidities, such as diabetes. Thus, the authors concluded that in some patients, it would be reasonable to consider limiting steroid use.

Bottom line: For patients with new-onset Bell’s palsy, steroids increase the probability of recovery of facial nerve function. Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is modest at best.

Citation: Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012;79(22):2209-2213.

Probiotic Prophylaxis Reduces Clostridium Difficile-Associated Diarrhea

Clinical question: Are probiotics a safe and efficacious therapy for the prevention of Clostridium difficile-associated diarrhea (CDAD)?

Background: CDAD is the most common cause of hospital-acquired infectious diarrhea in high-income countries. There has been a dramatic rise in the incidence and severity of CDAD since 2002. Previous studies suggested that probiotics might reduce the incidence of CDAD with few adverse events.

Study design: Systematic review and meta-analysis of the literature.

Setting: Randomized controlled trials from the U.S., Canada, Chile, China, United Kingdom, Turkey, Poland, and Sweden.

Synopsis: Investigators identified 20 trials including 3,818 participants using a systematic search of randomized controlled trials of a specified probiotic of any strain in adults or pediatric subjects treated with antibiotics. Probiotics reduced the incidence of CDAD by 66% (risk ratio 0.34, 95% CI 0.24 to 0.49). Subgroup analyses showed similar results in both adults and children, with lower and high doses, and with different probiotic species.

Of probiotic-treated patients, 9.3% experienced an adverse event compared with 12.6% of control patients (relative risk 0.82, 95% CI 0.65 to 1.05). There was no report of any serious adverse events attributable to probiotics.

One limitation is the considerable variability in the reported risk of CDAD in the control group (0% to 40%). The absolute benefit from probiotics will depend on the risk in patients who do not receive prophylaxis.

Bottom line: Moderate-quality evidence suggests that probiotic prophylaxis results in a large reduction in C. diff-associated diarrhea without an increase in clinically important adverse events.

Citation: Johnston BC, Ma SSY, Goldenberg JZ, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):878-888.

Rates of Hemorrhage from Warfarin Therapy Higher in Clinical Practice

Clinical question: What is the incidence of hemorrhage in a large population-based cohort of patients with atrial fibrillation who have started warfarin therapy?

Background: There is strong evidence that supports the use of warfarin to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. There are currently no large studies offering real-world, population-based estimates of hemorrhage rates among patients taking warfarin.

Study design: Retrospective cohort study.

Setting: Ontario.

Synopsis: This population-based, cohort study included 125,195 residents of Ontario age ≥66 years with atrial fibrillation who started taking warfarin sometime from 1997 to 2008. Hemorrhage was defined as bleeding requiring an emergency department visit or hospital admission. The overall risk of hemorrhage was 3.8% per person-year, but it was 11.8% in the first 30 days of therapy. For subjects age >75 years, the overall risk was 4.6% compared with 2.9% for those between 66 and 75 years.

Most hospital admissions involved gastrointestinal hemorrhages (63%). Almost 1 in 5 people (18%) with hospital admissions for hemorrhages died in the hospital or within seven days of discharge.

Bottom line: Rates of hemorrhage for older patients on warfarin therapy are significantly higher in clinical practice than the rates reported in clinical trials. The difference is likely due to the strict inclusion criteria, younger average age, and close monitoring of patients in clinical trials.

Citation: Gomes T, Mamdani MM, Holbrook AM, Paterson JM, Hellings C, Juurlink DN. Rates of hemorrhage during warfarin therapy for atrial fibrillation. CMAJ. 2013; Jan 21 [Epub ahead of print].

Less Experienced Doctors Incur Higher Treatment Costs

Clinical question: Which physician characteristics are associated with higher cost profiles?

Background: While both public and private insurers increasingly use physician cost profiles to identify physicians whose practice patterns account for more healthcare spending than other physicians, the individual physician characteristics associated with cost-profile performance are unknown.

Study design: Retrospective cohort study.

Setting: Four commercial health plans in Massachusetts.

Synopsis: Data collected from the insurance claims records of 1.13 million patients aged 18-65 years who were enrolled in one of four commercial health plans in Massachusetts in 2004 and 2005 were matched with the public records of 12,116 doctors who were stratified into five groups according to years of experience (<10, 10-19, 20-29, 30-39, and ≥40 years).

A strong association was found between physician experience and cost profiles, with the most experienced doctors—40 or more years of experience—providing the least costly care. Costs increased with each successively less experienced group (by 2.5%, 6.5%, 10%, and 13.2% more, respectively, to treat the same condition). No association was found between cost profiles and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and practice size.

Differences appear to be driven by high-cost outlier patients. While median costs were similar between physicians with different levels of experience, the costs of treating patients at the 95 percentile of cost were much higher among physicians with less experience.

Bottom line: Doctors in this study with the least experience incurred 13.2% greater costs than their most senior counterparts.

Citation: Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463.

Pay-For-Performance Incentive Reduces Mortality in England

Clinical question: Do pay-for-performance programs improve quality of care?

Background: Pay-for-performance programs are being widely adopted both internationally and in the U.S. There is, however, limited evidence that these programs improve patient outcomes, and most prior studies have shown modest or inconsistent improvements in quality of care.

Study design: Prospective cohort study.

Setting: National Health Service (NHS) hospitals in northwest England.

Synopsis: The Advanced Quality program, the first hospital-based pay-for-performance program in England, was introduced in October 2004 in all 24 NHS hospitals in northwest England that provide emergency care. The program used a “tournament” system in which only the top-performing hospitals received bonus payments. There was no penalty for poor performers.

The primary end-point was 30-day in-hospital mortality among patients admitted for pneumonia, heart failure, or acute myocardial infarction. Over the three-year period studied (18 months before and 18 months after introduction of the program), the risk-adjusted mortality for these three conditions decreased significantly with an absolute reduction of 1.3% (95% CI 0.4 to 2.1%; P=0.006). The largest change, for pneumonia, was significant (1.9%, 95% CI 0.9 to 3.0, P<0.001), with nonsignificant reductions for acute myocardial infarction (0.6%, 95% CI -0.4 to 1.7; P=0.23) and heart failure (0.6%, 95% CI -0.6 to 1.8; P=0.30).

Bottom line: The introduction of a pay-for-performance program for all National Health Service hospitals in one region of England was associated with a significant reduction in mortality.

Citation: Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. Reduced mortality with hospital pay for performance in England. N Engl J Med. 2012;367(19):1821-1828.

Ultrafiltration Shows No Benefit in Acute Heart Failure

Clinical question: Is ultrafiltration superior to pharmacotherapy in the treatment of patients with acute heart failure and cardiorenal syndrome?

Background: Venovenous ultrafiltration is an alternative to diuretic therapy in patients with acute decompensated heart failure and worsened renal function that could allow greater control of the rate of fluid removal and improve outcomes. Little is known about the efficacy and safety of ultrafiltration compared to standard pharmacological therapy.

Study design: Multicenter randomized controlled trial.

Setting: Fourteen clinical centers in the U.S. and Canada.

Synopsis: One hundred eighty-eight patients admitted to a hospital with acute decompensated heart failure and worsened renal function were randomized to stepped pharmacological therapy or ultrafiltration. Ultrafiltration was inferior to pharmacological therapy with respect to the pre-specified primary composite endpoint, the change in serum creatinine level, and body weight at 96 hours after enrollment (P=0.003). This difference was primarily due to an increase in the serum creatinine level in the ultrafiltration group (0.23 vs. -0.04 mg/dl; P=0.003). There was no significant difference in weight loss at 96 hours (loss of 5.5 kg vs. 5.7kg; P=0.58).

A higher percentage of patients in the ultrafiltration group had a serious adverse event over the 60-day follow-up period (72% vs. 57%, P=0.03). There was no significant difference in the composite rate of death or rehospitalization for heart failure in the ultrafiltration group compared to the pharmacologic-therapy group (38% vs. 35%; P=0.96).

Bottom line: Pharmacological therapy is superior to ultrafiltration in patients with acute decompensated heart failure and worsened renal function.

Citation: Bart BA, Goldsmith SR, Lee KL, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367:2296-2304.

Hospitalized Patients Often Receive Too Much Acetaminophen

Clinical question: What are the prevalence and factors associated with supratherapeutic dosing of acetaminophen in hospitalized patients?

Background: Acetaminophen is a commonly used medication that at high doses can be associated with significant adverse events, including liver failure. Considerable efforts have been made in the outpatient setting to limit the risks associated with acetaminophen. Little research has examined acetaminophen exposure in the inpatient setting.

Study design: Retrospective cohort study.

Setting: Two academic tertiary-care hospitals in the U.S.

Synopsis: The authors reviewed the electronic medication administration record of all adult patients admitted to two academic hospitals from June 1, 2010, to Aug. 31, 2010. A total of 14,411 patients (60.7%) were prescribed acetaminophen, of whom 955 (6.6%) were prescribed more than the 4g per day (the maximum recommended daily dose) at least once. In addition, 22.3% of patients >65 and 17.6% of patients with chronic liver disease exceeded the recommended limit of 3g per day. Half the supratherapeutic episodes involved doses exceeding 5g a day, often for several days. In adjusted analyses, scheduled administration (rather than as needed), a diagnosis of osteoarthritis, and higher-strength tablets were all associated with a higher risk of exposure to supratherapeutic doses.

Bottom line: A significant proportion of hospitalized patients are exposed to supratherapeutic dosing of acetaminophen.

Citation: Zhou L, Maviglia SM, Mahoney LM, et al. Supra-therapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012;172(22):1721-1728.

Longer Anticoagulation Therapy after Bioprosthetic Aortic Valve Replacement Might Be Beneficial

Clinical question: How long should anticoagulation therapy with warfarin be continued after surgical bioprosthetic aortic valve replacement?

Background: Current guidelines recommend a three-month course of anticoagulation therapy after bioprosthetic aortic valve surgery. However, the appropriate duration of post-operative anticoagulation therapy has not been well established

Study design: Retrospective cohort study.

Setting: Denmark.

Synopsis: Using data from the Danish National Registries, 4,075 subjects without atrial fibrillation who underwent bioprosthetic aortic valve implantation from 1997 to 2009 were identified. The association between different durations of warfarin therapy after aortic valve implantation and the combined end point of stroke, thromboembolic events, cardiovascular death, or bleeding episodes was examined.

The risk of adverse outcomes was substantially higher for patients not treated with warfarin compared to treated patents. The estimated adverse event rate was 7 per 100 person-years for untreated patients versus 2.7 per 100 for warfarin-treated patients (adjusted incidence rate ratio [IRR] 2.46, 95% CI 1.09 to 6.48). Patients not treated with warfarin were at higher risk of cardiovascular death within 30 to 89 days after surgery, with an event rate of 31.7 per 100 person-years versus 3.8 per 100 person-years (adjusted IRR 7.61, 95% CI 4.37 to 13.26). The difference in cardiovascular mortality continued to be significant from 90 to 179 days after surgery, with an event rate of 6.5 per 100 person-years versus 2.1 per 100 person-years (IRR 3.51, 95% CI 1.54 to 8.03).

Bottom line: Discontinuation of warfarin therapy within six months of bioprosthetic aortic valve replacement is associated with increased cardiovascular death.

Citation: Mérie C, Køber L, Skov Olsen P, et al. Association of warfarin therapy duration after bioprosthetic aortic valve replacement with risk of mortality, thromboembolic complications, and bleeding. JAMA. 2012;308(20):2118-2125.

Limited Evidence for Antimicrobial-Coated Catheters

Clinical question: Does the use of antimicrobial-coated catheters reduce the risk of catheter-associated urinary tract infection (UTI) compared to standard polytetrafluoroethylene (PTFE) catheters?

Background: UTIs associated with indwelling catheters are a major preventable cause of harm for hospitalized patients. Prior studies have shown that catheters made with antimicrobial coatings can reduce rates of bacteriuria, but their usefulness against symptomatic catheter-associated UTIs remains uncertain.

Study design: Multicenter randomized controlled trial.

Setting: Twenty-four hospitals in the United Kingdom.

Synopsis: A total of 7,102 patients >16 undergoing urethral catheterization for an anticipated duration of <14 days were randomly allocated in a 1:1:1 ratio to receive a silver-alloy-coated catheter, a nitrofural-impregnated silicone catheter, or a standard PTFE-coated catheter. The primary outcome was defined as presence of patient-reported symptoms of UTI and prescription of antibiotic for UTI. Incidence of symptomatic catheter-associated UTI up to six weeks after randomization did not differ significantly between groups and occurred in 12.6% of the PTFE control, 12.5% of the silver alloy group, and 10.6% of the nitrofural group. In secondary outcomes, the nitrofural catheter was associated with a slightly reduced incidence of culture-confirmed symptomatic UTI (absolute risk reduction of 1.4%) and lower rate of bacteriuria, but it also had greater patient-reported discomfort during use and removal.

Bottom line: Antimicrobial-coated catheters do not show a clinically significant benefit over standard PTFE catheters in preventing catheter-associated UTI.

Citation: Pickard R, Lam T, Maclennan G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomized controlled trial. Lancet. 2012;380:1927-1935.

Outcomes Improve after In-Hospital Cardiac Arrest

Clinical question: Have outcomes after in-hospital cardiac arrest improved with recent advances in resuscitation care?

Background: Over the past decade, quality-improvement (QI) efforts in hospital resuscitation care have included use of mock cardiac arrests, defibrillation by nonmedical personnel, and participation in QI registries. It is unclear what effect these efforts have had on overall survival and neurologic recovery.

Study design: Retrospective cohort study.

Setting: Five hundred fifty-three hospitals in the U.S.

Synopsis: A total of 113,514 patients age >18 with a cardiac arrest occurring from Jan. 1, 2000, to Nov. 19, 2009, were identified. Analyses were separated by initial rhythm (PEA/asystole or ventricular fibrillation/tachycardia). Overall survival to discharge increased significantly to 22.3% in 2009 from 13.7% in 2000, with similar increases within each rhythm group. Rates of acute resuscitation survival (return of spontaneous circulation for at least 20 contiguous minutes after initial arrest) and post-resuscitation survival (survival to discharge among patients surviving acute resuscitation) also improved during the study period. Rates of clinically significant neurologic disability, as defined by cerebral performance scores >1, decreased over time for the overall cohort and the subset with ventricular fibrillation/tachycardia. The study was limited by including only hospitals motivated to participate in a QI registry.

Bottom line: From 2000 to 2009, survival after in-hospital cardiac arrest improved, and rates of clinically significant neurologic disability among survivors decreased.

Citation: Girotra S, Nallamothu B, Spertus J, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367:1912-1920.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

Dr. Greeno

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.

—Brad Flansbaum, DO, MPH, SFHM, Lenox Hill Hospital, New York City, SHM Public Policy Committee member

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

Dr. Greeno

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.

—Brad Flansbaum, DO, MPH, SFHM, Lenox Hill Hospital, New York City, SHM Public Policy Committee member

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

Dr. Greeno

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.

—Brad Flansbaum, DO, MPH, SFHM, Lenox Hill Hospital, New York City, SHM Public Policy Committee member

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.