Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

The designers of the hospital value-based purchasing (HVBP) program sought to include outcomes measures in 2014, and when they did, mortality was their choice. Specifically, HVBP for fiscal-year 2014 (starting October 2013) will include 30-day mortality rates for myocardial infarction, heart failure, and pneumonia. The weighting for the mortality domain will be 25% (see Table 1).

click for large version

To review the requirements for the HVBP program in FY2014: All hospitals will have 1.25% of their Medicare inpatient payments withheld. They can earn back none, some, all, or an amount in excess of the 1.25%, depending on performance in the performance domains. To put it in perspective, 1.25% of Medicare inpatient payments for a 320-bed hospital are about $1 million. Such a hospital will have about $250,000 at risk in the mortality domain in FY2014.

Given the role hospitalists play in quality and safety initiatives, and the importance of medical record documentation in defining the risk of mortality and severity of illness, we can be crucial players in how our hospitals perform with regard to mortality.

Focus Areas for Mortality Reduction

Although many hospitalists might think that reducing mortality is like “boiling the ocean,” there are some areas where we can clearly focus our attention. There are four priority areas we should target in the coming years (also see Figure 1):

Reduce harm. This may take the form of reducing hospital-acquired infections, such as catheter-related UTIs, Clostridium difficile, and central-line-associated bloodstream infections, or reducing hospital-acquired VTE, falls, and delirium. Many hospital-acquired conditions have a collection, or bundle, of preventive practices. Hospitalists can work both in an institutional leadership capacity and in the course of daily clinical practice to implement bundles and best practices to reduce patient harm.

click for large version

Improve teamwork. With hospitalists, “you started to have teams caring for inpatients in a coordinated way. So I regard this as [hospitalists] coming into their own, their vision of the future starting to really take hold,” said Brent James, coauthor of the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Partly, we’ve accomplished this through simply “showing up” and partly we’ve done it through becoming students of the art and science of teamwork. An example of teamwork training, developed by the Defense Department and the Agency for Healthcare Quality and Research (AHRQ), is TeamSTEPPS, which offers a systematic approach to cooperation, coordination, and communication among team members. Optimal patient resuscitation, in-hospital handoffs, rapid-response teams, and early-warning systems are essential pieces of teamwork that may reduce mortality.

Improve evidence-based care. This domain covers process measures aimed at optimizing care, including reducing mortality. For HVBP in particular, myocardial infarction, heart failure, and pneumonia are the focus.

Improve transitions of care. Best practices for care transitions and reducing readmissions, including advance-care planning, involvement of palliative care and hospice, and coordination with post-acute care, can be a key part of reducing 30-day mortality.

Documentation Integrity

Accurately capturing a patient’s condition in the medical record is crucial to assigning severity of illness and risk of mortality. Because mortality rates are severity-adjusted, accurate documentation is another important dimension to potentially improving a hospital’s performance with regard to the mortality domain. This is one more reason to work closely with your hospital’s documentation specialists.

Don’t Be Afraid...

Proponents of mortality as a quality measure point to it as the ultimate reflection of the care provided. While moving the needle might seem like a task too big to undertake, a disciplined approach to the elements of the driver diagram combined with a robust documentation program can provide your institution with a tangible focus on this definitive measure.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

The designers of the hospital value-based purchasing (HVBP) program sought to include outcomes measures in 2014, and when they did, mortality was their choice. Specifically, HVBP for fiscal-year 2014 (starting October 2013) will include 30-day mortality rates for myocardial infarction, heart failure, and pneumonia. The weighting for the mortality domain will be 25% (see Table 1).

click for large version

To review the requirements for the HVBP program in FY2014: All hospitals will have 1.25% of their Medicare inpatient payments withheld. They can earn back none, some, all, or an amount in excess of the 1.25%, depending on performance in the performance domains. To put it in perspective, 1.25% of Medicare inpatient payments for a 320-bed hospital are about $1 million. Such a hospital will have about $250,000 at risk in the mortality domain in FY2014.

Given the role hospitalists play in quality and safety initiatives, and the importance of medical record documentation in defining the risk of mortality and severity of illness, we can be crucial players in how our hospitals perform with regard to mortality.

Focus Areas for Mortality Reduction

Although many hospitalists might think that reducing mortality is like “boiling the ocean,” there are some areas where we can clearly focus our attention. There are four priority areas we should target in the coming years (also see Figure 1):

Reduce harm. This may take the form of reducing hospital-acquired infections, such as catheter-related UTIs, Clostridium difficile, and central-line-associated bloodstream infections, or reducing hospital-acquired VTE, falls, and delirium. Many hospital-acquired conditions have a collection, or bundle, of preventive practices. Hospitalists can work both in an institutional leadership capacity and in the course of daily clinical practice to implement bundles and best practices to reduce patient harm.

click for large version

Improve teamwork. With hospitalists, “you started to have teams caring for inpatients in a coordinated way. So I regard this as [hospitalists] coming into their own, their vision of the future starting to really take hold,” said Brent James, coauthor of the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Partly, we’ve accomplished this through simply “showing up” and partly we’ve done it through becoming students of the art and science of teamwork. An example of teamwork training, developed by the Defense Department and the Agency for Healthcare Quality and Research (AHRQ), is TeamSTEPPS, which offers a systematic approach to cooperation, coordination, and communication among team members. Optimal patient resuscitation, in-hospital handoffs, rapid-response teams, and early-warning systems are essential pieces of teamwork that may reduce mortality.

Improve evidence-based care. This domain covers process measures aimed at optimizing care, including reducing mortality. For HVBP in particular, myocardial infarction, heart failure, and pneumonia are the focus.

Improve transitions of care. Best practices for care transitions and reducing readmissions, including advance-care planning, involvement of palliative care and hospice, and coordination with post-acute care, can be a key part of reducing 30-day mortality.

Documentation Integrity

Accurately capturing a patient’s condition in the medical record is crucial to assigning severity of illness and risk of mortality. Because mortality rates are severity-adjusted, accurate documentation is another important dimension to potentially improving a hospital’s performance with regard to the mortality domain. This is one more reason to work closely with your hospital’s documentation specialists.

Don’t Be Afraid...

Proponents of mortality as a quality measure point to it as the ultimate reflection of the care provided. While moving the needle might seem like a task too big to undertake, a disciplined approach to the elements of the driver diagram combined with a robust documentation program can provide your institution with a tangible focus on this definitive measure.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

The designers of the hospital value-based purchasing (HVBP) program sought to include outcomes measures in 2014, and when they did, mortality was their choice. Specifically, HVBP for fiscal-year 2014 (starting October 2013) will include 30-day mortality rates for myocardial infarction, heart failure, and pneumonia. The weighting for the mortality domain will be 25% (see Table 1).

click for large version

To review the requirements for the HVBP program in FY2014: All hospitals will have 1.25% of their Medicare inpatient payments withheld. They can earn back none, some, all, or an amount in excess of the 1.25%, depending on performance in the performance domains. To put it in perspective, 1.25% of Medicare inpatient payments for a 320-bed hospital are about $1 million. Such a hospital will have about $250,000 at risk in the mortality domain in FY2014.

Given the role hospitalists play in quality and safety initiatives, and the importance of medical record documentation in defining the risk of mortality and severity of illness, we can be crucial players in how our hospitals perform with regard to mortality.

Focus Areas for Mortality Reduction

Although many hospitalists might think that reducing mortality is like “boiling the ocean,” there are some areas where we can clearly focus our attention. There are four priority areas we should target in the coming years (also see Figure 1):

Reduce harm. This may take the form of reducing hospital-acquired infections, such as catheter-related UTIs, Clostridium difficile, and central-line-associated bloodstream infections, or reducing hospital-acquired VTE, falls, and delirium. Many hospital-acquired conditions have a collection, or bundle, of preventive practices. Hospitalists can work both in an institutional leadership capacity and in the course of daily clinical practice to implement bundles and best practices to reduce patient harm.

click for large version

Improve teamwork. With hospitalists, “you started to have teams caring for inpatients in a coordinated way. So I regard this as [hospitalists] coming into their own, their vision of the future starting to really take hold,” said Brent James, coauthor of the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Partly, we’ve accomplished this through simply “showing up” and partly we’ve done it through becoming students of the art and science of teamwork. An example of teamwork training, developed by the Defense Department and the Agency for Healthcare Quality and Research (AHRQ), is TeamSTEPPS, which offers a systematic approach to cooperation, coordination, and communication among team members. Optimal patient resuscitation, in-hospital handoffs, rapid-response teams, and early-warning systems are essential pieces of teamwork that may reduce mortality.

Improve evidence-based care. This domain covers process measures aimed at optimizing care, including reducing mortality. For HVBP in particular, myocardial infarction, heart failure, and pneumonia are the focus.

Improve transitions of care. Best practices for care transitions and reducing readmissions, including advance-care planning, involvement of palliative care and hospice, and coordination with post-acute care, can be a key part of reducing 30-day mortality.

Documentation Integrity

Accurately capturing a patient’s condition in the medical record is crucial to assigning severity of illness and risk of mortality. Because mortality rates are severity-adjusted, accurate documentation is another important dimension to potentially improving a hospital’s performance with regard to the mortality domain. This is one more reason to work closely with your hospital’s documentation specialists.

Don’t Be Afraid...

Proponents of mortality as a quality measure point to it as the ultimate reflection of the care provided. While moving the needle might seem like a task too big to undertake, a disciplined approach to the elements of the driver diagram combined with a robust documentation program can provide your institution with a tangible focus on this definitive measure.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Research on seriously ill, hospitalized, Medicare-age patients finds that those who received inpatient consultations from a multidisciplinary, palliative-care team (including a physician, nurse, and social worker) had lower 30-day hospital readmission rates.¹ Ten percent of discharged patients who received the palliative-care consult were readmitted within 30 days at an urban HMO medical center in Los Angeles County during the same period, even though they were sicker than the overall discharged population.

Receipt of hospice care or home-based palliative-care services following discharge was also associated with significantly lower rates of readmissions, suggesting opportunities for systemic cost savings from earlier access to longitudinal, or ongoing, palliative-care services, says Susan Enguidanos, MPH, PhD, assistant professor of gerontology at the University of Southern California in Los Angeles. Patients discharged from the hospital without any follow-up care in the home had higher odds of readmission.

“Hospitals and medical centers should seriously consider an inpatient palliative care consultation team for many reasons, mostly arising from findings from other studies that have demonstrated improved quality of life, pain and symptom management, satisfaction with medical care, and other promising outcomes,” Dr. Enguidanos says. “Our study suggests that longitudinal palliative care is also associated with the lower readmission rate.”

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Research on seriously ill, hospitalized, Medicare-age patients finds that those who received inpatient consultations from a multidisciplinary, palliative-care team (including a physician, nurse, and social worker) had lower 30-day hospital readmission rates.¹ Ten percent of discharged patients who received the palliative-care consult were readmitted within 30 days at an urban HMO medical center in Los Angeles County during the same period, even though they were sicker than the overall discharged population.

Receipt of hospice care or home-based palliative-care services following discharge was also associated with significantly lower rates of readmissions, suggesting opportunities for systemic cost savings from earlier access to longitudinal, or ongoing, palliative-care services, says Susan Enguidanos, MPH, PhD, assistant professor of gerontology at the University of Southern California in Los Angeles. Patients discharged from the hospital without any follow-up care in the home had higher odds of readmission.

“Hospitals and medical centers should seriously consider an inpatient palliative care consultation team for many reasons, mostly arising from findings from other studies that have demonstrated improved quality of life, pain and symptom management, satisfaction with medical care, and other promising outcomes,” Dr. Enguidanos says. “Our study suggests that longitudinal palliative care is also associated with the lower readmission rate.”

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Research on seriously ill, hospitalized, Medicare-age patients finds that those who received inpatient consultations from a multidisciplinary, palliative-care team (including a physician, nurse, and social worker) had lower 30-day hospital readmission rates.¹ Ten percent of discharged patients who received the palliative-care consult were readmitted within 30 days at an urban HMO medical center in Los Angeles County during the same period, even though they were sicker than the overall discharged population.

Receipt of hospice care or home-based palliative-care services following discharge was also associated with significantly lower rates of readmissions, suggesting opportunities for systemic cost savings from earlier access to longitudinal, or ongoing, palliative-care services, says Susan Enguidanos, MPH, PhD, assistant professor of gerontology at the University of Southern California in Los Angeles. Patients discharged from the hospital without any follow-up care in the home had higher odds of readmission.

“Hospitals and medical centers should seriously consider an inpatient palliative care consultation team for many reasons, mostly arising from findings from other studies that have demonstrated improved quality of life, pain and symptom management, satisfaction with medical care, and other promising outcomes,” Dr. Enguidanos says. “Our study suggests that longitudinal palliative care is also associated with the lower readmission rate.”

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Data reported at the American Heart Association’s scientific sessions in Los Angeles in November suggest that when a cardiologist, rather than a hospitalist, is the attending physician for a hospitalized heart failure patient, readmission is less likely. Casey M. Lawler, MD, FACC, a cardiologist at the Minneapolis Heart Institute, says her center began establishing protocols to improve heart failure readmissions rates five years ago, after determining that many patients did not understand their diagnosis or treatment. “Thus, we became much more involved in post-discharge care,” including the phoning of discharged patients and follow-up with primary-care providers.

When the heart failure patients’ attending physicians were cardiologists, their readmission rate was 16%, versus 27.1% with hospitalists, even though their severity of illness was higher. Length of stay was similar for both groups and total mean costs were higher for the patients managed by cardiologists. “Although these results reveal that specialists have a positive impact on readmission rates, an overhaul to an entire healthcare system’s treatment of [heart failure] patients—from admission to post-discharge follow-up—is required to truly impact preventable readmissions,” Dr. Lawler asserted.

In the Minneapolis study, 65% of the 2,300 heart failure patients were managed by hospitalists, and 35% by cardiologists. A recent national survey of advanced heart failure programs found that cardiologists managed the care of acute HF patients more than 60 percent of the time.²

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Data reported at the American Heart Association’s scientific sessions in Los Angeles in November suggest that when a cardiologist, rather than a hospitalist, is the attending physician for a hospitalized heart failure patient, readmission is less likely. Casey M. Lawler, MD, FACC, a cardiologist at the Minneapolis Heart Institute, says her center began establishing protocols to improve heart failure readmissions rates five years ago, after determining that many patients did not understand their diagnosis or treatment. “Thus, we became much more involved in post-discharge care,” including the phoning of discharged patients and follow-up with primary-care providers.

When the heart failure patients’ attending physicians were cardiologists, their readmission rate was 16%, versus 27.1% with hospitalists, even though their severity of illness was higher. Length of stay was similar for both groups and total mean costs were higher for the patients managed by cardiologists. “Although these results reveal that specialists have a positive impact on readmission rates, an overhaul to an entire healthcare system’s treatment of [heart failure] patients—from admission to post-discharge follow-up—is required to truly impact preventable readmissions,” Dr. Lawler asserted.

In the Minneapolis study, 65% of the 2,300 heart failure patients were managed by hospitalists, and 35% by cardiologists. A recent national survey of advanced heart failure programs found that cardiologists managed the care of acute HF patients more than 60 percent of the time.²

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Data reported at the American Heart Association’s scientific sessions in Los Angeles in November suggest that when a cardiologist, rather than a hospitalist, is the attending physician for a hospitalized heart failure patient, readmission is less likely. Casey M. Lawler, MD, FACC, a cardiologist at the Minneapolis Heart Institute, says her center began establishing protocols to improve heart failure readmissions rates five years ago, after determining that many patients did not understand their diagnosis or treatment. “Thus, we became much more involved in post-discharge care,” including the phoning of discharged patients and follow-up with primary-care providers.

When the heart failure patients’ attending physicians were cardiologists, their readmission rate was 16%, versus 27.1% with hospitalists, even though their severity of illness was higher. Length of stay was similar for both groups and total mean costs were higher for the patients managed by cardiologists. “Although these results reveal that specialists have a positive impact on readmission rates, an overhaul to an entire healthcare system’s treatment of [heart failure] patients—from admission to post-discharge follow-up—is required to truly impact preventable readmissions,” Dr. Lawler asserted.

In the Minneapolis study, 65% of the 2,300 heart failure patients were managed by hospitalists, and 35% by cardiologists. A recent national survey of advanced heart failure programs found that cardiologists managed the care of acute HF patients more than 60 percent of the time.²

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

A poster presented at HM12 in San Diego last April describes a standardized, systematic, multidisciplinary clinical pathway for treating acute VTE (venous thromboembolism) in an urban hospital serving a high proportion of the uninsured.³ Implementing the pathway in February 2011 “dramatically reduced hospital utilization and cost, particularly among uninsured patients,” who were previously shown to have increased length of stay, cost, and emergency department recidivism, says lead author Gregory Misky, MD, a hospitalist at the University of Colorado Denver.

The pathway—which aimed to standardize all VTE care from hospital presentation to post-discharge follow-up—contained multiple components, including education for staff, enhanced communication processes, written order sets, and a series of formal and informal meetings held with community providers, such as the clinics where these patients get their follow-up primary care. Dr. Misky collaborated with his university’s anticoagulation clinic to help identify primary-care physicians and clinics and arrange follow-up outpatient appointments much sooner than the patients could have obtained by themselves.

The prospective study compared 135 VTE patients presenting to the emergency department or admitted to a medicine service and receiving care under the pathway, compared with 234 VTE patients prior to its introduction. Length of stay dropped to 2.5 days from 4.2, and for uninsured patients it dropped even more, to 2.2 days from 5.5.

Dr. Misky says the data gathered since the San Diego conference “continue to show good results in resource utilization, particularly for the uninsured, with emergency department visits and readmissions slashed.” Readmissions have dropped to 5.2% from 9.8%—and to 3.5% from 11.6% for uninsured VTE patients. He suggests that the clinical pathway approach likely has implications for other diseases as well.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

A poster presented at HM12 in San Diego last April describes a standardized, systematic, multidisciplinary clinical pathway for treating acute VTE (venous thromboembolism) in an urban hospital serving a high proportion of the uninsured.³ Implementing the pathway in February 2011 “dramatically reduced hospital utilization and cost, particularly among uninsured patients,” who were previously shown to have increased length of stay, cost, and emergency department recidivism, says lead author Gregory Misky, MD, a hospitalist at the University of Colorado Denver.

The pathway—which aimed to standardize all VTE care from hospital presentation to post-discharge follow-up—contained multiple components, including education for staff, enhanced communication processes, written order sets, and a series of formal and informal meetings held with community providers, such as the clinics where these patients get their follow-up primary care. Dr. Misky collaborated with his university’s anticoagulation clinic to help identify primary-care physicians and clinics and arrange follow-up outpatient appointments much sooner than the patients could have obtained by themselves.

The prospective study compared 135 VTE patients presenting to the emergency department or admitted to a medicine service and receiving care under the pathway, compared with 234 VTE patients prior to its introduction. Length of stay dropped to 2.5 days from 4.2, and for uninsured patients it dropped even more, to 2.2 days from 5.5.

Dr. Misky says the data gathered since the San Diego conference “continue to show good results in resource utilization, particularly for the uninsured, with emergency department visits and readmissions slashed.” Readmissions have dropped to 5.2% from 9.8%—and to 3.5% from 11.6% for uninsured VTE patients. He suggests that the clinical pathway approach likely has implications for other diseases as well.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

A poster presented at HM12 in San Diego last April describes a standardized, systematic, multidisciplinary clinical pathway for treating acute VTE (venous thromboembolism) in an urban hospital serving a high proportion of the uninsured.³ Implementing the pathway in February 2011 “dramatically reduced hospital utilization and cost, particularly among uninsured patients,” who were previously shown to have increased length of stay, cost, and emergency department recidivism, says lead author Gregory Misky, MD, a hospitalist at the University of Colorado Denver.

The pathway—which aimed to standardize all VTE care from hospital presentation to post-discharge follow-up—contained multiple components, including education for staff, enhanced communication processes, written order sets, and a series of formal and informal meetings held with community providers, such as the clinics where these patients get their follow-up primary care. Dr. Misky collaborated with his university’s anticoagulation clinic to help identify primary-care physicians and clinics and arrange follow-up outpatient appointments much sooner than the patients could have obtained by themselves.

The prospective study compared 135 VTE patients presenting to the emergency department or admitted to a medicine service and receiving care under the pathway, compared with 234 VTE patients prior to its introduction. Length of stay dropped to 2.5 days from 4.2, and for uninsured patients it dropped even more, to 2.2 days from 5.5.

Dr. Misky says the data gathered since the San Diego conference “continue to show good results in resource utilization, particularly for the uninsured, with emergency department visits and readmissions slashed.” Readmissions have dropped to 5.2% from 9.8%—and to 3.5% from 11.6% for uninsured VTE patients. He suggests that the clinical pathway approach likely has implications for other diseases as well.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

David Lawrence, MD, retired head of the Kaiser Foundation health plan, says in a recent Information Week article that it will be “nearly impossible” to achieve the goals of healthcare integration without the connectivity of a well-designed health IT system.⁴ Dr. Lawrence was a member of a committee that authored the recent report Order from Chaos: Accelerating Care Integration for the Lucian Leape Institute at the National Patient Care Safety Foundation. Failures of coordination most often happen during the crucial information transfers that happen during care transitions, but there has not been enough attention to how important information technology could be to these transfers, Dr. Lawrence told the magazine. “It’s the really complex stuff where this becomes particularly critical,” he said.

The federal Office of Inspector General (OIG) took the Centers for Medicare & Medicaid Services (CMS) to task in a November report for not having adequate oversight or safeguards for its EHR meaningful-use program.⁵ As a result, OIG described Medicare as “vulnerable” to fraud and abuse of incentive payments made to hospitals and health professionals, according to OIG. OIG recommends that CMS request and review supporting documentation for selected providers and issue guidance with specific examples of appropriate documentation. As of September 2012, CMS had paid out $4 billion in meaningful-use incentives to 1,400 hospitals and 82,000 professionals.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

David Lawrence, MD, retired head of the Kaiser Foundation health plan, says in a recent Information Week article that it will be “nearly impossible” to achieve the goals of healthcare integration without the connectivity of a well-designed health IT system.⁴ Dr. Lawrence was a member of a committee that authored the recent report Order from Chaos: Accelerating Care Integration for the Lucian Leape Institute at the National Patient Care Safety Foundation. Failures of coordination most often happen during the crucial information transfers that happen during care transitions, but there has not been enough attention to how important information technology could be to these transfers, Dr. Lawrence told the magazine. “It’s the really complex stuff where this becomes particularly critical,” he said.

The federal Office of Inspector General (OIG) took the Centers for Medicare & Medicaid Services (CMS) to task in a November report for not having adequate oversight or safeguards for its EHR meaningful-use program.⁵ As a result, OIG described Medicare as “vulnerable” to fraud and abuse of incentive payments made to hospitals and health professionals, according to OIG. OIG recommends that CMS request and review supporting documentation for selected providers and issue guidance with specific examples of appropriate documentation. As of September 2012, CMS had paid out $4 billion in meaningful-use incentives to 1,400 hospitals and 82,000 professionals.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

David Lawrence, MD, retired head of the Kaiser Foundation health plan, says in a recent Information Week article that it will be “nearly impossible” to achieve the goals of healthcare integration without the connectivity of a well-designed health IT system.⁴ Dr. Lawrence was a member of a committee that authored the recent report Order from Chaos: Accelerating Care Integration for the Lucian Leape Institute at the National Patient Care Safety Foundation. Failures of coordination most often happen during the crucial information transfers that happen during care transitions, but there has not been enough attention to how important information technology could be to these transfers, Dr. Lawrence told the magazine. “It’s the really complex stuff where this becomes particularly critical,” he said.

The federal Office of Inspector General (OIG) took the Centers for Medicare & Medicaid Services (CMS) to task in a November report for not having adequate oversight or safeguards for its EHR meaningful-use program.⁵ As a result, OIG described Medicare as “vulnerable” to fraud and abuse of incentive payments made to hospitals and health professionals, according to OIG. OIG recommends that CMS request and review supporting documentation for selected providers and issue guidance with specific examples of appropriate documentation. As of September 2012, CMS had paid out $4 billion in meaningful-use incentives to 1,400 hospitals and 82,000 professionals.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.