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Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.
Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?
The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”
There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”
Start at Self-Assessment
Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.
Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.
How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).
Identify Core Leadership Requirements
There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.
Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.
The hospitalist leader is responsible for many tasks, the authors write, including:
- Blending marketplace needs with those of these various stakeholders;
- Managing budgets, billing and revenue cycles, resources, and performance metrics; and
- Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.
These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.
Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”
Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”
Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”
Leadership Self-Assessment
The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).
Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.
A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.
You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.
Pursue the Right Training Venues
Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.
Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).
The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.
A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).
Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.
Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.
Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.
Advanced Training
For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.
The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.
An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.
“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.
A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”
Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.
Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.
Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.
As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.
“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.
Veteran Advice For Aspiring HM leaders
Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate long-term relationships.
Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.
Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.
Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.
Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?
The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”
There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”
Start at Self-Assessment
Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.
Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.
How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).
Identify Core Leadership Requirements
There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.
Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.
The hospitalist leader is responsible for many tasks, the authors write, including:
- Blending marketplace needs with those of these various stakeholders;
- Managing budgets, billing and revenue cycles, resources, and performance metrics; and
- Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.
These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.
Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”
Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”
Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”
Leadership Self-Assessment
The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).
Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.
A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.
You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.
Pursue the Right Training Venues
Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.
Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).
The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.
A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).
Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.
Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.
Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.
Advanced Training
For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.
The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.
An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.
“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.
A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”
Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.
Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.
Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.
As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.
“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.
Veteran Advice For Aspiring HM leaders
Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate long-term relationships.
Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.
Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.
Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.
Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?
The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”
There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”
Start at Self-Assessment
Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.
Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.
How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).
Identify Core Leadership Requirements
There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.
Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.
The hospitalist leader is responsible for many tasks, the authors write, including:
- Blending marketplace needs with those of these various stakeholders;
- Managing budgets, billing and revenue cycles, resources, and performance metrics; and
- Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.
These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.
Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”
Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”
Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”
Leadership Self-Assessment
The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).
Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.
A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.
You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.
Pursue the Right Training Venues
Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.
Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).
The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.
A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).
Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.
Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.
Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.
Advanced Training
For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.
The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.
An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.
“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.
A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”
Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.
Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.
Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.
As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.
“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.
Veteran Advice For Aspiring HM leaders
Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate long-term relationships.
Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.
Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.
Infection-prevention professionals, hospital officials suggest steps to simplify and streamline HAI tracking system
Infection-prevention leaders and state hospital association representatives participated in regional meetings sponsored across the country during the summer of 2009 by the U.S. Department of Health and Human Services (HHS) and suggested ways that the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN)—a leading federal system for tracking healthcare-associated infections (HAIs)—could be made easier for hospitals. Participants recommended steps to reduce data-collection burdens and to increase usefulness for hospital infection prevention and quality-improvement (QI) programs.
HHS convened the regional meetings to get stakeholders’ input into HHS’ Action Plan to Prevent Healthcare-Associated Infections (www.hhs.gov/ophs/initiatives/hai/index.html), as well as to hear about their experiences with the network. The action plan is a blueprint for HAI prevention and sets specific targets for monitoring and preventing HAIs nationally. Leaders from various HHS agencies, including the Agency for Healthcare Research and Quality (AHRQ), CDC, Centers for Medicare and Medicaid Services (CMS), the National Institutes of Health (NIH), and the Office of Public Health and Science joined me in discussing participants’ concerns at these meetings.
HHS uses NHSN data to help monitor progress toward the action plan goals. Twenty-eight states require hospitals to report HAIs publicly; most use the NHSN (www.cdc.gov/nhsn). Hospital enrollment in the NHSN has increased dramatically, to more than 2,700 hospitals in mid-2010 from 300 in 2005.
Daniel Pollock, MD, the surveillance branch chief for CDC’s Division of Healthcare Quality Promotion, and I reported on CDC’s efforts to update the NHSN and improve its ease of use. Simplifying and streamlining the system, and assuring sufficient technical capacity and user support, are top priorities. For example:
- CDC has instituted changes in data collection requirements for healthcare-associated urinary tract infections into the NHSN application;
- More NHSN staff were hired to perform comprehensive assessments and upgrades of the system’s technical infrastructure and usability, and to provide additional user support for enrollment and training;
- NHSN will begin migrating this fall to a new system of authenticating users; and
- NHSN Web pages are being redesigned to speed response times during peak use.
Dr. Pollock emphasized that the CDC is committed to accelerating the transition from manual to electronic case detection and reporting for the NHSN, and leveraging advances in health information technology as a primary strategy for enhancing the NHSN. As part of that effort, NHSN now is accepting electronic infection records submitted by hospitals that use commercial infection control surveillance systems.
The CDC continues to work closely with AHRQ, CMS, and the Office of the National Coordinator for Health Information Technology to coordinate integration efforts of federal information systems that provide HAI data. That is part of our commitment here in Washington to support hospitals’ efforts to reduce and eliminate HAIs, and to make healthcare safer for patients and families.
Don Wright, MD, MPH,
deputy assistant secretary for healthcare quality,
U.S. Department of Health and Human Services
Infection-prevention leaders and state hospital association representatives participated in regional meetings sponsored across the country during the summer of 2009 by the U.S. Department of Health and Human Services (HHS) and suggested ways that the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN)—a leading federal system for tracking healthcare-associated infections (HAIs)—could be made easier for hospitals. Participants recommended steps to reduce data-collection burdens and to increase usefulness for hospital infection prevention and quality-improvement (QI) programs.
HHS convened the regional meetings to get stakeholders’ input into HHS’ Action Plan to Prevent Healthcare-Associated Infections (www.hhs.gov/ophs/initiatives/hai/index.html), as well as to hear about their experiences with the network. The action plan is a blueprint for HAI prevention and sets specific targets for monitoring and preventing HAIs nationally. Leaders from various HHS agencies, including the Agency for Healthcare Research and Quality (AHRQ), CDC, Centers for Medicare and Medicaid Services (CMS), the National Institutes of Health (NIH), and the Office of Public Health and Science joined me in discussing participants’ concerns at these meetings.
HHS uses NHSN data to help monitor progress toward the action plan goals. Twenty-eight states require hospitals to report HAIs publicly; most use the NHSN (www.cdc.gov/nhsn). Hospital enrollment in the NHSN has increased dramatically, to more than 2,700 hospitals in mid-2010 from 300 in 2005.
Daniel Pollock, MD, the surveillance branch chief for CDC’s Division of Healthcare Quality Promotion, and I reported on CDC’s efforts to update the NHSN and improve its ease of use. Simplifying and streamlining the system, and assuring sufficient technical capacity and user support, are top priorities. For example:
- CDC has instituted changes in data collection requirements for healthcare-associated urinary tract infections into the NHSN application;
- More NHSN staff were hired to perform comprehensive assessments and upgrades of the system’s technical infrastructure and usability, and to provide additional user support for enrollment and training;
- NHSN will begin migrating this fall to a new system of authenticating users; and
- NHSN Web pages are being redesigned to speed response times during peak use.
Dr. Pollock emphasized that the CDC is committed to accelerating the transition from manual to electronic case detection and reporting for the NHSN, and leveraging advances in health information technology as a primary strategy for enhancing the NHSN. As part of that effort, NHSN now is accepting electronic infection records submitted by hospitals that use commercial infection control surveillance systems.
The CDC continues to work closely with AHRQ, CMS, and the Office of the National Coordinator for Health Information Technology to coordinate integration efforts of federal information systems that provide HAI data. That is part of our commitment here in Washington to support hospitals’ efforts to reduce and eliminate HAIs, and to make healthcare safer for patients and families.
Don Wright, MD, MPH,
deputy assistant secretary for healthcare quality,
U.S. Department of Health and Human Services
Infection-prevention leaders and state hospital association representatives participated in regional meetings sponsored across the country during the summer of 2009 by the U.S. Department of Health and Human Services (HHS) and suggested ways that the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN)—a leading federal system for tracking healthcare-associated infections (HAIs)—could be made easier for hospitals. Participants recommended steps to reduce data-collection burdens and to increase usefulness for hospital infection prevention and quality-improvement (QI) programs.
HHS convened the regional meetings to get stakeholders’ input into HHS’ Action Plan to Prevent Healthcare-Associated Infections (www.hhs.gov/ophs/initiatives/hai/index.html), as well as to hear about their experiences with the network. The action plan is a blueprint for HAI prevention and sets specific targets for monitoring and preventing HAIs nationally. Leaders from various HHS agencies, including the Agency for Healthcare Research and Quality (AHRQ), CDC, Centers for Medicare and Medicaid Services (CMS), the National Institutes of Health (NIH), and the Office of Public Health and Science joined me in discussing participants’ concerns at these meetings.
HHS uses NHSN data to help monitor progress toward the action plan goals. Twenty-eight states require hospitals to report HAIs publicly; most use the NHSN (www.cdc.gov/nhsn). Hospital enrollment in the NHSN has increased dramatically, to more than 2,700 hospitals in mid-2010 from 300 in 2005.
Daniel Pollock, MD, the surveillance branch chief for CDC’s Division of Healthcare Quality Promotion, and I reported on CDC’s efforts to update the NHSN and improve its ease of use. Simplifying and streamlining the system, and assuring sufficient technical capacity and user support, are top priorities. For example:
- CDC has instituted changes in data collection requirements for healthcare-associated urinary tract infections into the NHSN application;
- More NHSN staff were hired to perform comprehensive assessments and upgrades of the system’s technical infrastructure and usability, and to provide additional user support for enrollment and training;
- NHSN will begin migrating this fall to a new system of authenticating users; and
- NHSN Web pages are being redesigned to speed response times during peak use.
Dr. Pollock emphasized that the CDC is committed to accelerating the transition from manual to electronic case detection and reporting for the NHSN, and leveraging advances in health information technology as a primary strategy for enhancing the NHSN. As part of that effort, NHSN now is accepting electronic infection records submitted by hospitals that use commercial infection control surveillance systems.
The CDC continues to work closely with AHRQ, CMS, and the Office of the National Coordinator for Health Information Technology to coordinate integration efforts of federal information systems that provide HAI data. That is part of our commitment here in Washington to support hospitals’ efforts to reduce and eliminate HAIs, and to make healthcare safer for patients and families.
Don Wright, MD, MPH,
deputy assistant secretary for healthcare quality,
U.S. Department of Health and Human Services
Stage Presence
For hospitalist Robert Wachter, MD, MHM, the next annual SHM meeting will be particularly poignant, and not just because he’s HM11’s featured speaker.
Next year will mark the 15th anniversary of the New England Journal of Medicine article coauthored by Dr. Wachter that introduced the term “hospitalist” to the American healthcare lexicon. The specialty is growing and developing into adulthood nicely, he says, which will be part of his presentation in Grapevine, Texas.
“At age 15, that’s when you move to adolescence—you’re going to be off on adulthood and on your own,” says Dr. Wachter, professor, chief of the Division of Hospital Medicine, and chief of the Medical Service at the University of California at San Francisco Medical Center, former SHM president and author of the blog Wachter’s World (www.wachtersworld.com).
Like a proud father, Dr. Wachter expects that he will reminisce about the past, speculate about HM’s bright future, and encourage hospitalists to continue their work.
“This will be an optimistic talk,” he says. “The growth has been extraordinary.”
At the outset of the specialty, Dr. Wachter says, he and colleagues predicted some of the current trends, but they underestimated how powerful some would become.
“We couldn’t have predicted that the pressures to increase quality and safety would be as intense as they are today, but we did a good job believing that these areas were important before they hit,” he says.
Looking forward, he says, other emerging forces will join quality and safety at the forefront of HM. “The next five years will likely bring similar pressures on efficiency and throughput,” he says. “I’m going to encourage folks to stay ahead of the curve.”
Having attended every annual conference since the beginning, Dr. Wachter looks forward to “polar things” about each meeting: catching up with the founders of the movement and seeing new faces.
“What’s more fun for me is the amount of youthful energy at the meetings,” he says, especially of the hospitalists he has mentored over the years. “When I come with my group from UCSF, it gives me tremendous pride.” TH
Brendon Shank is a freelance writer based in Philadelphia.
Chapter Updates
Lake Erie
The Lake Erie/Northern Ohio chapter met Aug. 24 at Lolita in Cleveland. Joseph G. Verbalis, MD, chief of the Division of Endocrinology and Metabolism and professor in the Department of Medicine at Georgetown University Medical Center in Washington, D.C., was the guest speaker, and his discussion was on hyponatremia. Sixteen area hospitalists attended the meeting, which was sponsored by CME University.
For hospitalist Robert Wachter, MD, MHM, the next annual SHM meeting will be particularly poignant, and not just because he’s HM11’s featured speaker.
Next year will mark the 15th anniversary of the New England Journal of Medicine article coauthored by Dr. Wachter that introduced the term “hospitalist” to the American healthcare lexicon. The specialty is growing and developing into adulthood nicely, he says, which will be part of his presentation in Grapevine, Texas.
“At age 15, that’s when you move to adolescence—you’re going to be off on adulthood and on your own,” says Dr. Wachter, professor, chief of the Division of Hospital Medicine, and chief of the Medical Service at the University of California at San Francisco Medical Center, former SHM president and author of the blog Wachter’s World (www.wachtersworld.com).
Like a proud father, Dr. Wachter expects that he will reminisce about the past, speculate about HM’s bright future, and encourage hospitalists to continue their work.
“This will be an optimistic talk,” he says. “The growth has been extraordinary.”
At the outset of the specialty, Dr. Wachter says, he and colleagues predicted some of the current trends, but they underestimated how powerful some would become.
“We couldn’t have predicted that the pressures to increase quality and safety would be as intense as they are today, but we did a good job believing that these areas were important before they hit,” he says.
Looking forward, he says, other emerging forces will join quality and safety at the forefront of HM. “The next five years will likely bring similar pressures on efficiency and throughput,” he says. “I’m going to encourage folks to stay ahead of the curve.”
Having attended every annual conference since the beginning, Dr. Wachter looks forward to “polar things” about each meeting: catching up with the founders of the movement and seeing new faces.
“What’s more fun for me is the amount of youthful energy at the meetings,” he says, especially of the hospitalists he has mentored over the years. “When I come with my group from UCSF, it gives me tremendous pride.” TH
Brendon Shank is a freelance writer based in Philadelphia.
Chapter Updates
Lake Erie
The Lake Erie/Northern Ohio chapter met Aug. 24 at Lolita in Cleveland. Joseph G. Verbalis, MD, chief of the Division of Endocrinology and Metabolism and professor in the Department of Medicine at Georgetown University Medical Center in Washington, D.C., was the guest speaker, and his discussion was on hyponatremia. Sixteen area hospitalists attended the meeting, which was sponsored by CME University.
For hospitalist Robert Wachter, MD, MHM, the next annual SHM meeting will be particularly poignant, and not just because he’s HM11’s featured speaker.
Next year will mark the 15th anniversary of the New England Journal of Medicine article coauthored by Dr. Wachter that introduced the term “hospitalist” to the American healthcare lexicon. The specialty is growing and developing into adulthood nicely, he says, which will be part of his presentation in Grapevine, Texas.
“At age 15, that’s when you move to adolescence—you’re going to be off on adulthood and on your own,” says Dr. Wachter, professor, chief of the Division of Hospital Medicine, and chief of the Medical Service at the University of California at San Francisco Medical Center, former SHM president and author of the blog Wachter’s World (www.wachtersworld.com).
Like a proud father, Dr. Wachter expects that he will reminisce about the past, speculate about HM’s bright future, and encourage hospitalists to continue their work.
“This will be an optimistic talk,” he says. “The growth has been extraordinary.”
At the outset of the specialty, Dr. Wachter says, he and colleagues predicted some of the current trends, but they underestimated how powerful some would become.
“We couldn’t have predicted that the pressures to increase quality and safety would be as intense as they are today, but we did a good job believing that these areas were important before they hit,” he says.
Looking forward, he says, other emerging forces will join quality and safety at the forefront of HM. “The next five years will likely bring similar pressures on efficiency and throughput,” he says. “I’m going to encourage folks to stay ahead of the curve.”
Having attended every annual conference since the beginning, Dr. Wachter looks forward to “polar things” about each meeting: catching up with the founders of the movement and seeing new faces.
“What’s more fun for me is the amount of youthful energy at the meetings,” he says, especially of the hospitalists he has mentored over the years. “When I come with my group from UCSF, it gives me tremendous pride.” TH
Brendon Shank is a freelance writer based in Philadelphia.
Chapter Updates
Lake Erie
The Lake Erie/Northern Ohio chapter met Aug. 24 at Lolita in Cleveland. Joseph G. Verbalis, MD, chief of the Division of Endocrinology and Metabolism and professor in the Department of Medicine at Georgetown University Medical Center in Washington, D.C., was the guest speaker, and his discussion was on hyponatremia. Sixteen area hospitalists attended the meeting, which was sponsored by CME University.
Fellow in Hospital Medicine Spotlight
Dr. Sherman, a hospitalist of 15 years, is both chairman and director of quality and performance improvement in the Department of Medicine at Glen Cove (N.Y.) Hospital, part of the North Shore University Health System. He is a clinical associate professor of medicine at New York University School of Medicine and an associate professor of medicine at Hofstra University School of Medicine.
A six-year SHM member, he helped establish the Long Island, N.Y., chapter and led as its president from 2004 to 2007. He served as moderator both for the transitions-in-care discussion and MRSA infections symposium at HM10 in Washington, D.C.
Undergraduate education: Duke University, Durham, N.C.
Graduate education: The Rockefeller University in New York City and New York Medical College in Valhalla, N.Y.
Internship and residency: Northwestern University, Chicago.
Fellowships: Gastroenterology fellowship at University of Pittsburgh from 1994 to 1995; fellowship in quality at Greater New York Hospital Association from 2009 to 2010.
Notable: This year, he completed a 15-month Six Sigma quality project on reducing variation care and standardization for patients admitted with heart failure, as well as a capstone project on reducing 30-day readmissions for patients discharged with heart failure.
Quotable: “Hospital medicine will continue to expand and become an integral part of hospital operations and practice. The comanagement services with surgical specialties will continue to evolve, and hospitalists will be taking a larger role in ensuring that care rendered across the continuum is met at the highest standard, both in and out of the hospital.”
FYI: Dr. Sherman enjoys spending time with his wife and two sons, ages 12 and 9. He is an avid tennis player and a regular at his local gym. —Sarah Gelotte
Dr. Sherman, a hospitalist of 15 years, is both chairman and director of quality and performance improvement in the Department of Medicine at Glen Cove (N.Y.) Hospital, part of the North Shore University Health System. He is a clinical associate professor of medicine at New York University School of Medicine and an associate professor of medicine at Hofstra University School of Medicine.
A six-year SHM member, he helped establish the Long Island, N.Y., chapter and led as its president from 2004 to 2007. He served as moderator both for the transitions-in-care discussion and MRSA infections symposium at HM10 in Washington, D.C.
Undergraduate education: Duke University, Durham, N.C.
Graduate education: The Rockefeller University in New York City and New York Medical College in Valhalla, N.Y.
Internship and residency: Northwestern University, Chicago.
Fellowships: Gastroenterology fellowship at University of Pittsburgh from 1994 to 1995; fellowship in quality at Greater New York Hospital Association from 2009 to 2010.
Notable: This year, he completed a 15-month Six Sigma quality project on reducing variation care and standardization for patients admitted with heart failure, as well as a capstone project on reducing 30-day readmissions for patients discharged with heart failure.
Quotable: “Hospital medicine will continue to expand and become an integral part of hospital operations and practice. The comanagement services with surgical specialties will continue to evolve, and hospitalists will be taking a larger role in ensuring that care rendered across the continuum is met at the highest standard, both in and out of the hospital.”
FYI: Dr. Sherman enjoys spending time with his wife and two sons, ages 12 and 9. He is an avid tennis player and a regular at his local gym. —Sarah Gelotte
Dr. Sherman, a hospitalist of 15 years, is both chairman and director of quality and performance improvement in the Department of Medicine at Glen Cove (N.Y.) Hospital, part of the North Shore University Health System. He is a clinical associate professor of medicine at New York University School of Medicine and an associate professor of medicine at Hofstra University School of Medicine.
A six-year SHM member, he helped establish the Long Island, N.Y., chapter and led as its president from 2004 to 2007. He served as moderator both for the transitions-in-care discussion and MRSA infections symposium at HM10 in Washington, D.C.
Undergraduate education: Duke University, Durham, N.C.
Graduate education: The Rockefeller University in New York City and New York Medical College in Valhalla, N.Y.
Internship and residency: Northwestern University, Chicago.
Fellowships: Gastroenterology fellowship at University of Pittsburgh from 1994 to 1995; fellowship in quality at Greater New York Hospital Association from 2009 to 2010.
Notable: This year, he completed a 15-month Six Sigma quality project on reducing variation care and standardization for patients admitted with heart failure, as well as a capstone project on reducing 30-day readmissions for patients discharged with heart failure.
Quotable: “Hospital medicine will continue to expand and become an integral part of hospital operations and practice. The comanagement services with surgical specialties will continue to evolve, and hospitalists will be taking a larger role in ensuring that care rendered across the continuum is met at the highest standard, both in and out of the hospital.”
FYI: Dr. Sherman enjoys spending time with his wife and two sons, ages 12 and 9. He is an avid tennis player and a regular at his local gym. —Sarah Gelotte
Hospitalists Flock to Free HM App for iPhone, BlackBerry, and Other Handhelds
In less than a year, a smartphone application has attracted the attention of hospitalists across the country. Thousands of individuals have accessed the new “Hospitalist Connection” app since it launched in April.
Developed by Epocrates, one of the leaders in mobile applications in healthcare, “Hospitalist Connection” delivers fresh perspectives and unique content about leading research in hospital medicine. Topics include practice management, quality improvement, and care transitions.
Recent articles have covered the effect that financial incentives can have on HM operations and an editorial from Chad Whelan, MD, FHM, physician editor of “Hospitalist Connection,” about the effects of “presenteeism,” or physicians working when the know they are sick.
“When they are on the job, downtime for hospitalists is rare and valuable,” says Dr. Whelan, director of the Division of Hospital Medicine and associate professor of medicine at Loyola University’s Stritch School of Medicine in Chicago.
“‘Hospitalist Connection’ is an easy way to stay informed on best practices in the field—from anywhere at any time.”
To download and subscribe to “Hospitalist Connection,” visit www.hospitalmedicine.org/epocrates.
For SHM, delivering content to smartphones is a logical move.
“This advances the specialty, and we’re thrilled to make it as easy as possible for our members and others to subscribe,” says Todd Von Deak, MBA, CAE, vice president of operations and general manager of SHM. “This is another tangible way that SHM is helping hospitalists improve the quality, safety, and efficiency of care in the hospital.”
In less than a year, a smartphone application has attracted the attention of hospitalists across the country. Thousands of individuals have accessed the new “Hospitalist Connection” app since it launched in April.
Developed by Epocrates, one of the leaders in mobile applications in healthcare, “Hospitalist Connection” delivers fresh perspectives and unique content about leading research in hospital medicine. Topics include practice management, quality improvement, and care transitions.
Recent articles have covered the effect that financial incentives can have on HM operations and an editorial from Chad Whelan, MD, FHM, physician editor of “Hospitalist Connection,” about the effects of “presenteeism,” or physicians working when the know they are sick.
“When they are on the job, downtime for hospitalists is rare and valuable,” says Dr. Whelan, director of the Division of Hospital Medicine and associate professor of medicine at Loyola University’s Stritch School of Medicine in Chicago.
“‘Hospitalist Connection’ is an easy way to stay informed on best practices in the field—from anywhere at any time.”
To download and subscribe to “Hospitalist Connection,” visit www.hospitalmedicine.org/epocrates.
For SHM, delivering content to smartphones is a logical move.
“This advances the specialty, and we’re thrilled to make it as easy as possible for our members and others to subscribe,” says Todd Von Deak, MBA, CAE, vice president of operations and general manager of SHM. “This is another tangible way that SHM is helping hospitalists improve the quality, safety, and efficiency of care in the hospital.”
In less than a year, a smartphone application has attracted the attention of hospitalists across the country. Thousands of individuals have accessed the new “Hospitalist Connection” app since it launched in April.
Developed by Epocrates, one of the leaders in mobile applications in healthcare, “Hospitalist Connection” delivers fresh perspectives and unique content about leading research in hospital medicine. Topics include practice management, quality improvement, and care transitions.
Recent articles have covered the effect that financial incentives can have on HM operations and an editorial from Chad Whelan, MD, FHM, physician editor of “Hospitalist Connection,” about the effects of “presenteeism,” or physicians working when the know they are sick.
“When they are on the job, downtime for hospitalists is rare and valuable,” says Dr. Whelan, director of the Division of Hospital Medicine and associate professor of medicine at Loyola University’s Stritch School of Medicine in Chicago.
“‘Hospitalist Connection’ is an easy way to stay informed on best practices in the field—from anywhere at any time.”
To download and subscribe to “Hospitalist Connection,” visit www.hospitalmedicine.org/epocrates.
For SHM, delivering content to smartphones is a logical move.
“This advances the specialty, and we’re thrilled to make it as easy as possible for our members and others to subscribe,” says Todd Von Deak, MBA, CAE, vice president of operations and general manager of SHM. “This is another tangible way that SHM is helping hospitalists improve the quality, safety, and efficiency of care in the hospital.”
A New Look at Family Medicine Hospitalists
A new survey spearheaded by SHM’s Family Medicine Task Force gives the first glimpse into the demographics, settings, and scopes of practice of this growing HM segment.
The research found that hospitalists trained in family medicine are experienced physicians who likely work directly for their hospital. More than half (51%) completed residency training more than 10 years ago, although the largest single group of respondents (37%) finished residency six to 10 years ago.
Virtually all respondents (96%) work full-time and a third are hospital employees—the most prevalent staffing model found in the survey. In addition to clinical practice, half of family-medicine-trained hospitalists have teaching and other leadership responsibilities.
The survey is based on responses from 81 of the 263 SHM members registered as family medicine physicians.
“As the number of family-medicine-trained physicians grows within hospital medicine, it’s important for us to understand the people behind it,” said research coauthor Claudia Geyer, MD, FHM.
Family-medicine-trained hospitalists are a growing phenomenon in the specialty. Survey data from 2007 to 2008 revealed that 3.7% of U.S. hospitalists are trained in family medicine; however, SHM’s recent membership data show that more than 6% of SHM members are registered as family medicine physicians.
A new survey spearheaded by SHM’s Family Medicine Task Force gives the first glimpse into the demographics, settings, and scopes of practice of this growing HM segment.
The research found that hospitalists trained in family medicine are experienced physicians who likely work directly for their hospital. More than half (51%) completed residency training more than 10 years ago, although the largest single group of respondents (37%) finished residency six to 10 years ago.
Virtually all respondents (96%) work full-time and a third are hospital employees—the most prevalent staffing model found in the survey. In addition to clinical practice, half of family-medicine-trained hospitalists have teaching and other leadership responsibilities.
The survey is based on responses from 81 of the 263 SHM members registered as family medicine physicians.
“As the number of family-medicine-trained physicians grows within hospital medicine, it’s important for us to understand the people behind it,” said research coauthor Claudia Geyer, MD, FHM.
Family-medicine-trained hospitalists are a growing phenomenon in the specialty. Survey data from 2007 to 2008 revealed that 3.7% of U.S. hospitalists are trained in family medicine; however, SHM’s recent membership data show that more than 6% of SHM members are registered as family medicine physicians.
A new survey spearheaded by SHM’s Family Medicine Task Force gives the first glimpse into the demographics, settings, and scopes of practice of this growing HM segment.
The research found that hospitalists trained in family medicine are experienced physicians who likely work directly for their hospital. More than half (51%) completed residency training more than 10 years ago, although the largest single group of respondents (37%) finished residency six to 10 years ago.
Virtually all respondents (96%) work full-time and a third are hospital employees—the most prevalent staffing model found in the survey. In addition to clinical practice, half of family-medicine-trained hospitalists have teaching and other leadership responsibilities.
The survey is based on responses from 81 of the 263 SHM members registered as family medicine physicians.
“As the number of family-medicine-trained physicians grows within hospital medicine, it’s important for us to understand the people behind it,” said research coauthor Claudia Geyer, MD, FHM.
Family-medicine-trained hospitalists are a growing phenomenon in the specialty. Survey data from 2007 to 2008 revealed that 3.7% of U.S. hospitalists are trained in family medicine; however, SHM’s recent membership data show that more than 6% of SHM members are registered as family medicine physicians.
Fellows Program Application Deadline is Jan. 14
Next year’s annual meeting in Dallas marks the third induction of fellows into the SHM Fellows program. Candidates still have a few weeks to submit an application. The deadline for 2011 applications is Jan. 14.
More than 700 fellows and senior fellows have been inducted since the program began in 2009. “The success and enthusiasm for this program has been incredible,” says Todd Von Deak, SHM’s vice president of operations and general manager. “For individual hospitalists, it’s a simple way to demonstrate to patients and hospitals that you take your profession very seriously. For the specialty, it illustrates the growth and accomplishments of hospital medicine to the rest of the healthcare sector.”
In addition to additional rights and privileges from SHM, fellows can append their designation to their name and credentials.
The SHM Fellows program inducts three levels of fellows every year: Fellow in Hospital Medicine (FHM), Senior Fellow in Hospital Medicine (SFHM), and Master in Hospital Medicine (MHM).
To be nominated, both FHM and SFHM designations require five years as a practicing hospitalist and a demonstrated commitment to quality improvement, teamwork, and leadership. An FHM candidate must be an SHM member for at least three years; SFHM candidates must be members for at least five.
Introduced last year, the MHM designation is by invitation only and reserved for the specialty’s leaders and pioneers. The inaugural MHM designees were John Nelson (pictured left), MD, MHM, Robert Watcher (center), MD, MHM, and Winthrop Whitcomb (right), MD, MHM.
For more information or an application, visit www.hospitalmedicine.org/fellows.
FELLOW IN HOSPITAL MEDICINE SPOTLIGHT
Bradley M. Sherman, MD, FACP, FHM
Dr. Sherman, a hospitalist of 15 years, is both chairman and director of quality and performance improvement in the Department of Medicine at Glen Cove (N.Y.) Hospital, part of the North Shore University Health System. He is a clinical associate professor of medicine at New York University School of Medicine and an associate professor of medicine at Hofstra University School of Medicine.
A six-year SHM member, he helped establish the Long Island, N.Y., chapter and led as its president from 2004 to 2007. He served as moderator both for the transitions-in-care discussion and MRSA infections symposium at HM10 in Washington, D.C.
Undergraduate education: Duke University, Durham, N.C.
Graduate education: The Rockefeller University in New York City and New York Medical College in Valhalla, N.Y.
Internship and residency: Northwestern University, Chicago.
Fellowships: Gastroenterology fellowship at University of Pittsburgh from 1994 to 1995; fellowship in quality at Greater New York Hospital Association from 2009 to 2010.
Notable: This year, he completed a 15-month Six Sigma quality project on reducing variation care and standardization for patients admitted with heart failure, as well as a capstone project on reducing 30-day readmissions for patients discharged with heart failure.
Quotable: “Hospital medicine will continue to expand and become an integral part of hospital operations and practice. The comanagement services with surgical specialties will continue to evolve, and hospitalists will be taking a larger role in ensuring that care rendered across the continuum is met at the highest standard, both in and out of the hospital.”
FYI: Dr. Sherman enjoys spending time with his wife and two sons, ages 12 and 9. He is an avid tennis player and a regular at his local gym. —Sarah Gelotte
Next year’s annual meeting in Dallas marks the third induction of fellows into the SHM Fellows program. Candidates still have a few weeks to submit an application. The deadline for 2011 applications is Jan. 14.
More than 700 fellows and senior fellows have been inducted since the program began in 2009. “The success and enthusiasm for this program has been incredible,” says Todd Von Deak, SHM’s vice president of operations and general manager. “For individual hospitalists, it’s a simple way to demonstrate to patients and hospitals that you take your profession very seriously. For the specialty, it illustrates the growth and accomplishments of hospital medicine to the rest of the healthcare sector.”
In addition to additional rights and privileges from SHM, fellows can append their designation to their name and credentials.
The SHM Fellows program inducts three levels of fellows every year: Fellow in Hospital Medicine (FHM), Senior Fellow in Hospital Medicine (SFHM), and Master in Hospital Medicine (MHM).
To be nominated, both FHM and SFHM designations require five years as a practicing hospitalist and a demonstrated commitment to quality improvement, teamwork, and leadership. An FHM candidate must be an SHM member for at least three years; SFHM candidates must be members for at least five.
Introduced last year, the MHM designation is by invitation only and reserved for the specialty’s leaders and pioneers. The inaugural MHM designees were John Nelson (pictured left), MD, MHM, Robert Watcher (center), MD, MHM, and Winthrop Whitcomb (right), MD, MHM.
For more information or an application, visit www.hospitalmedicine.org/fellows.
FELLOW IN HOSPITAL MEDICINE SPOTLIGHT
Bradley M. Sherman, MD, FACP, FHM
Dr. Sherman, a hospitalist of 15 years, is both chairman and director of quality and performance improvement in the Department of Medicine at Glen Cove (N.Y.) Hospital, part of the North Shore University Health System. He is a clinical associate professor of medicine at New York University School of Medicine and an associate professor of medicine at Hofstra University School of Medicine.
A six-year SHM member, he helped establish the Long Island, N.Y., chapter and led as its president from 2004 to 2007. He served as moderator both for the transitions-in-care discussion and MRSA infections symposium at HM10 in Washington, D.C.
Undergraduate education: Duke University, Durham, N.C.
Graduate education: The Rockefeller University in New York City and New York Medical College in Valhalla, N.Y.
Internship and residency: Northwestern University, Chicago.
Fellowships: Gastroenterology fellowship at University of Pittsburgh from 1994 to 1995; fellowship in quality at Greater New York Hospital Association from 2009 to 2010.
Notable: This year, he completed a 15-month Six Sigma quality project on reducing variation care and standardization for patients admitted with heart failure, as well as a capstone project on reducing 30-day readmissions for patients discharged with heart failure.
Quotable: “Hospital medicine will continue to expand and become an integral part of hospital operations and practice. The comanagement services with surgical specialties will continue to evolve, and hospitalists will be taking a larger role in ensuring that care rendered across the continuum is met at the highest standard, both in and out of the hospital.”
FYI: Dr. Sherman enjoys spending time with his wife and two sons, ages 12 and 9. He is an avid tennis player and a regular at his local gym. —Sarah Gelotte
Next year’s annual meeting in Dallas marks the third induction of fellows into the SHM Fellows program. Candidates still have a few weeks to submit an application. The deadline for 2011 applications is Jan. 14.
More than 700 fellows and senior fellows have been inducted since the program began in 2009. “The success and enthusiasm for this program has been incredible,” says Todd Von Deak, SHM’s vice president of operations and general manager. “For individual hospitalists, it’s a simple way to demonstrate to patients and hospitals that you take your profession very seriously. For the specialty, it illustrates the growth and accomplishments of hospital medicine to the rest of the healthcare sector.”
In addition to additional rights and privileges from SHM, fellows can append their designation to their name and credentials.
The SHM Fellows program inducts three levels of fellows every year: Fellow in Hospital Medicine (FHM), Senior Fellow in Hospital Medicine (SFHM), and Master in Hospital Medicine (MHM).
To be nominated, both FHM and SFHM designations require five years as a practicing hospitalist and a demonstrated commitment to quality improvement, teamwork, and leadership. An FHM candidate must be an SHM member for at least three years; SFHM candidates must be members for at least five.
Introduced last year, the MHM designation is by invitation only and reserved for the specialty’s leaders and pioneers. The inaugural MHM designees were John Nelson (pictured left), MD, MHM, Robert Watcher (center), MD, MHM, and Winthrop Whitcomb (right), MD, MHM.
For more information or an application, visit www.hospitalmedicine.org/fellows.
FELLOW IN HOSPITAL MEDICINE SPOTLIGHT
Bradley M. Sherman, MD, FACP, FHM
Dr. Sherman, a hospitalist of 15 years, is both chairman and director of quality and performance improvement in the Department of Medicine at Glen Cove (N.Y.) Hospital, part of the North Shore University Health System. He is a clinical associate professor of medicine at New York University School of Medicine and an associate professor of medicine at Hofstra University School of Medicine.
A six-year SHM member, he helped establish the Long Island, N.Y., chapter and led as its president from 2004 to 2007. He served as moderator both for the transitions-in-care discussion and MRSA infections symposium at HM10 in Washington, D.C.
Undergraduate education: Duke University, Durham, N.C.
Graduate education: The Rockefeller University in New York City and New York Medical College in Valhalla, N.Y.
Internship and residency: Northwestern University, Chicago.
Fellowships: Gastroenterology fellowship at University of Pittsburgh from 1994 to 1995; fellowship in quality at Greater New York Hospital Association from 2009 to 2010.
Notable: This year, he completed a 15-month Six Sigma quality project on reducing variation care and standardization for patients admitted with heart failure, as well as a capstone project on reducing 30-day readmissions for patients discharged with heart failure.
Quotable: “Hospital medicine will continue to expand and become an integral part of hospital operations and practice. The comanagement services with surgical specialties will continue to evolve, and hospitalists will be taking a larger role in ensuring that care rendered across the continuum is met at the highest standard, both in and out of the hospital.”
FYI: Dr. Sherman enjoys spending time with his wife and two sons, ages 12 and 9. He is an avid tennis player and a regular at his local gym. —Sarah Gelotte
In the Literature: HM-Related Research You Need to Know
In This Edition
Literature at a Glance
A guide to this month’s studies
- Continuous insulin infusion in non-ICU patients
- How hospitalists spend their day
- Outcomes of patients leaving against medical advice
- Prediction rule for readmission
- Effects of high- vs. low-dose PPIs for peptic ulcer
- Hospital utilization by generalists before hospitalists
- Effect of hospitalist fragmentation on length of stay
- Medication errors at admissions in older patients
Continuous Insulin Infusion Provides Effective Glycemic Control in Non-ICU Patients
Clinical question: Is continuous insulin infusion (CII) a safe and effective option in the management of hyperglycemia in non-ICU patients?
Background: Hyperglycemia has been associated with worse outcomes in hospitalized patients. Prior research has demonstrated the benefit of CII in managing hyperglycemia in the ICU setting. However, outcomes have not been evaluated in the general medical (non-ICU) setting, where hyperglycemia is often inadequately addressed.
Study design: Retrospective chart review.
Setting: Urban tertiary-care medical center.
Synopsis: Charts of 200 adult patients treated with CII in non-ICU areas were reviewed with the primary outcomes including mean daily blood glucose (BG) levels and number of hyper- and hypoglycemic events occurring on CII. Mean BG dropped from 323 mg/dL to 182 mg/dL by day one, with a BG≤of 150 achieved in 67% of patients by day two of therapy. Twenty-two percent of patients suffered a hypoglycemic event (BG<60), reportedly similar to prior studies of insulin use in ICU and non-ICU settings. Eighty-two percent of patients received some form of nutritional support while on CII. In multivariate analyses, receiving oral nutrition (either a solid or liquid diet) was the only factor associated with increased risk of hyperglycemia and hypoglycemia.
This study was limited by its retrospective analysis in a single center. No comparison was made with basal-bolus or sliding-scale insulin therapy regarding efficacy or safety.
Bottom line: Non-ICU patients with hyperglycemia who received CII were able to achieve effective glycemic control within 48 hours of initiation, with rates of hypoglycemia comparable to those observed in ICU settings.
Citation: Smiley D, Rhee M, Peng L, et al. Safety and efficacy of continuous insulin infusion in noncritical care settings. J Hosp Med. 2010;5(4):212-217.
Hospitalists Spend More Time on Indirect, Rather Than Direct, Patient Care
Clinical question: What are the components of the daily workflow of hospitalists working on a non-housestaff service?
Background: The use of hospitalists is associated with increased efficiency in the hospital setting. However, it is not known how this efficiency is achieved. Prior literature has attempted to address this question, but with increasing demands and patient census, the representativeness of existing data is unclear.
Study design: Observational time-motion study.
Setting: Urban tertiary-care academic medical center.
Synopsis: Twenty-four hospitalists were directly observed for two weekday shifts. An electronic collection tool was developed using initial data on hospitalist activities and piloted prior to formal study data collection. Direct patient care was defined as involving face-to-face interaction between hospitalist and patient, while indirect patient care involved activities relevant to patient care but not performed in the patient’s presence.
Approximately 500 hours of observation were collected. Direct patient care comprised only a mean of 17.4% of the hospitalists’ daily workflow, while more was spent on indirect care, mainly electronic health record (EHR) documentation (mean 34.1%) and communication activities (mean 25.9%). Multitasking occurred 16% of the time, typically during communication or “critical documentation activities” (e.g. writing prescriptions). As patient volume increased, less time was spent in communication, and documentation was deferred to after hours.
These results were consistent with prior observational studies but were limited to a single center and might not represent the workflow of hospitalists in other settings, such as community hospitals, or nocturnists.
Bottom line: Hospitalists on non-housestaff services spend most of their time on indirect patient care and, with increasing patient census, communication is sacrificed. Multitasking is common during periods of communication and critical documentation.
Citation: Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go?—a time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.
Patients Who Leave Against Medical Advice Have Higher Readmission, Mortality Rates
Clinical question: What are the 30-day hospital readmission and mortality rates for Veterans Administration (VA) patients discharged against medical advice (AMA) compared with those appropriately discharged from the hospital?
Background: Patients discharged AMA might be at increased risk of experiencing worse outcomes. Small studies have demonstrated that patients with asthma and acute myocardial infarction (MI) discharged AMA have increased risk of readmission and death. However, it is unclear whether these risks are generalizable to a wider medical population.
Study design: Five-year retrospective cohort study.
Setting: One hundred twenty-nine VA acute-care hospitals.
Synopsis: Of the nearly 2 million patients admitted to the VA from 2004 to 2008, 1.7% were discharged AMA. Patients discharged AMA generally were younger, had lower incomes, and were more likely to be black. Furthermore, patients discharged AMA had statistically significant higher rates of 30-day readmission (17.7% vs. 11%, P<0.001) and higher 30-day mortality rates (0.75% vs. 0.61%, P=0.001) compared with those who had been appropriately discharged. In hazard models, discharge AMA was a significant predictor of 30-day readmission and conferred a nonstatistically significant increase in 30-day mortality.
Because all patients were seen in VA facilities, the results might not be generalizable to other acute-care settings. Although VA patients differ from the general medical population, the characteristics of patients discharged AMA are similar to those in previously published studies. The study utilized administrative data, which are very reliable but limited by little information on clinical factors that could contribute to AMA discharges.
Bottom line: Patients discharged AMA are at increased risk of worse post-hospitalization outcomes, including hospital readmission and death.
Citation: Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9): 926-929.
Simple Model Predicts Hospital Readmission
Clinical question: Which patient-level factors can be used in a simple model to predict hospital readmission of medicine patients?
Background: Hospital readmissions are common and costly. Previously published readmission prediction models have had limited utility because they focused on a specific condition, setting, or population, or were too cumbersome for practical use.
Study design: Prospective observational cohort study.
Setting: Six academic medical centers.
Synopsis: Data from nearly 11,000 general medicine patients were included in the analysis. Overall, almost 18% of patients were readmitted within 30 days of discharge.
In the prediction model derived and validated from the data, seven factors were significant predictors of readmission within 30 days of discharge: insurance status, marital status, having a regular healthcare provider, Charlson comorbidity index, SF 12 physical component score, one or more admissions within the last year, and current length of stay greater than two days. Points assigned from each significant predictor were used to create a risk score. The 5% of patients with risk scores of 25 and higher had 30-day readmission rates of approximately 30%, compared to readmission rates of approximately 16% in patients with scores of less than 25.
These results might not be generalizable to small, rural, nonacademic settings. Planned admissions could not be excluded from the data, and readmissions to nonstudy hospitals could not be ascertained. Despite these limitations, this model is easier to use than prior models and relevant to a broad population of patients.
Bottom line: A simple prediction model using patient-level factors can be used to identify patients at higher risk of readmission within 30 days of discharge to home.
Citation: Hasan O, Meltzer DO, Shaykevich SA, et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211-219.
No Difference in Outcomes Between High- and Non-High-Dose Proton Pump Inhibitors in Bleeding Peptic Ulcers
Clinical question: Do high-dose proton pump inhibitors (PPIs) decrease the rate of rebleeding, surgical intervention, or mortality in patients with bleeding peptic ulcers who have undergone endoscopic treatment?
Background: Previous studies have demonstrated superiority of both high- and low-dose PPIs to H2 receptor antagonists and placebo in reducing rebleeding rates in patients with peptic ulcers. However, no clear evidence is available to suggest that high-dose PPIs are more effective than non-high-dose PPIs for treatment of bleeding peptic ulcers.
Study design: Systematic review and meta-analysis.
Setting: Multicenter and single-site studies conducted in several countries.
Synopsis: Studies were included if they were randomized controlled trials, compared high- versus non-high-dose PPIs, evaluated endoscopically confirmed bleeding ulcers, gave PPIs after endoscopy, and documented outcomes regarding rates of rebleeding, surgical intervention, or mortality. High-dose PPIs were defined as equivalent to omeprazole 80 mg intravenous bolus followed by continuous intravenous infusion at 8 mg/hr for 72 hours.
Seven studies met inclusion criteria. The pooled odds ratios for rebleeding, surgical intervention, and mortality were 1.30 (95% CI, 0.88-1.91), 1.49 (95% CI, 0.66-3.37), and 0.89 (95% CI, 0.37-2.13), respectively, for high-dose versus non-high-dose PPIs. The authors concluded that high-dose PPIs were not superior to non-high-dose PPIs in reducing the rates of these adverse outcomes after endoscopic treatment of bleeding ulcers. Considering the cost of high-dose PPIs, further studies are indicated to help guide PPI dosing for patients with peptic ulcers.
Major limitations of this study were the small number of studies (1,157 patients in total) and their heterogeneity, and the lack of intention-to-treat analysis. The studies also included a high Asian predominance, and it has been shown that Asian populations have an enhanced PPI effect.
Bottom line: High-dose PPIs did not demonstrate reduced rates of ulcer rebleeding, surgical intervention, or mortality compared with non-high-dose PPIs in this meta-analysis, which included a small number of studies and patients.
Citation: Wang CH, Ma MH, Chou HC, et al. High-dose vs. non-high-dose proton pump inhibitors after endoscopic treatment in patients with bleeding peptic ulcer: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2010;170(9):751-758.
Hospital Utilization by Practicing Generalists Declined before the Emergence of Hospitalists
Clinical question: What has been the pattern of hospital utilization by generalists before and after the emergence of hospitalists?
Background: It has been proposed that the emergence of hospitalists has “crowded out” generalist physicians from the U.S. hospital setting. This study evaluated the trends of inpatient practice by generalists both before and after the emergence of hospitalists.
Study design: Retrospective analysis of national databases.
Setting: U.S. data from 1980 to 2005.
Synopsis: Utilizing the National Hospital Discharge Survey and the American Medical Association’s Physician Characteristics and Distribution in the U.S., information was extracted to evaluate the average number of annual inpatient encounters relative to generalist workforce from 1980 to 2005. Total inpatient encounters for each year were calculated by multiplying the total number of hospital admissions by the average hospital length of stay. The emergence of hospitalists was defined as beginning in 1994.
Total inpatient encounters by generalists declined by 35% in the pre-hospitalist era but remained essentially unchanged in the hospitalist era. During the pre-hospitalist period, the number of generalists doubled, to more than 200,000 from approximately 100,000, while the number of hospital discharges remained relatively stable and the length of stay declined by a third. The decrease in average inpatient encounters in the pre-hospitalist era is thought to have been secondary to decreased length of stay and increased workforce.
Bottom line: Hospital utilization relative to generalist physician workforce was decreasing prior to the emergence of hospitalists mainly due to decreased length of hospital stay and increased numbers of physicians.
Citation: Meltzer DO, Chung JW. U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists. J Gen Intern Med. 2010;25(5):453-459.
Fragmentation of Hospitalist Care Is Associated with Increased Length of Stay
Clinical question: Does fragmentation of care (FOC) by hospitalists affect length of stay (LOS)?
Background: Previous investigations have explored the impact of FOC provided by residency programs on LOS and quality of care. Results of these studies have been mixed. However, there have been no prior studies on the impact of the fragmentation of hospitalist care on LOS.
Study design: Concurrent control study.
Setting: Hospitalist practices all over the country managed by IPC: The Hospitalist Company.
Synopsis: Investigators looked at 10,977 patients admitted with diagnoses of pneumonia or heart failure. The primary endpoint was LOS. The independent variable of interest was a measure of FOC. The FOC was calculated as a quantitative index, by determining the percentage of hospitalist care delivered by a physician other than the primary hospitalist.
Multivariable analyses revealed a statistically significant increase in LOS of 0.39 days for each 10% increase in fragmentation level for pneumonia admissions. Similarly, for patients with heart failure, there was a significant increase in LOS of 0.30 days for each 10% increase in fragmentation level.
The study is a concurrent control study, so conclusions cannot be drawn about causality. Additionally, there are likely unmeasured differences between every hospital and hospitalist practice, which could further confound the relationships between hospitalist care and LOS.
Bottom line: Fragmentation of care provided by hospitalists is associated with an increased LOS in patients hospitalized for pneumonia or heart failure.
Citation: Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5(6):335-338.
Admission Medication Errors Are Common and Most Harmful in Older Patients Taking Many Medications
Clinical question: What are the risk factors and potential harm associated with medication errors at hospital admission?
Background: Obtaining a medication history from a hospitalized patient is an error-prone process. Several variables can affect the completeness and quality of medication histories, but existing data are limited regarding patient or medication risk factors associated with medication errors at admission.
Study design: Prospective cohort study.
Setting: Academic hospital in Chicago.
Synopsis: Pharmacist and admitting physician medication histories were compared with admission medication orders to identify any unexplained discrepancies. Discrepancies resulting in order changes were defined as medication errors.
Of the 651 adult medical inpatients studied, 234 (35.9%) had medication order errors identified at admission. Errors originated in the medication histories for 85% of these patients. The most frequent type of error was an omission (48.9%). An age of 65 or older (odds ratio [OR]=2.17, 95% confidence interval [CI], 1.09-4.30) and increased number of medications (OR=1.21, 95% CI, 1.14-1.29) were the only risk factors identified by multivariate analysis to be independently associated with increased risk of medication order errors potentially causing harm or requiring monitoring or intervention. Presenting a medication list upon admission was a significant protective factor (OR=0.35, 95% CI, 0.19-0.63).
Though this is the largest study to date evaluating admission medication errors in hospitalized medical patients, it remains limited by its single hospital site. Because the authors were unable to interview patients who were too ill or unwilling to participate and had no caregiver present, they might have underestimated the number of admission errors. Further, the harm assessment was based on potential and not actual harm.
Bottom line: Admission medication order errors are frequent, most commonly originate in the medication histories, and have increased potential to cause adverse outcomes in older patients and those taking higher numbers of medications.
Citation: Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447.
In This Edition
Literature at a Glance
A guide to this month’s studies
- Continuous insulin infusion in non-ICU patients
- How hospitalists spend their day
- Outcomes of patients leaving against medical advice
- Prediction rule for readmission
- Effects of high- vs. low-dose PPIs for peptic ulcer
- Hospital utilization by generalists before hospitalists
- Effect of hospitalist fragmentation on length of stay
- Medication errors at admissions in older patients
Continuous Insulin Infusion Provides Effective Glycemic Control in Non-ICU Patients
Clinical question: Is continuous insulin infusion (CII) a safe and effective option in the management of hyperglycemia in non-ICU patients?
Background: Hyperglycemia has been associated with worse outcomes in hospitalized patients. Prior research has demonstrated the benefit of CII in managing hyperglycemia in the ICU setting. However, outcomes have not been evaluated in the general medical (non-ICU) setting, where hyperglycemia is often inadequately addressed.
Study design: Retrospective chart review.
Setting: Urban tertiary-care medical center.
Synopsis: Charts of 200 adult patients treated with CII in non-ICU areas were reviewed with the primary outcomes including mean daily blood glucose (BG) levels and number of hyper- and hypoglycemic events occurring on CII. Mean BG dropped from 323 mg/dL to 182 mg/dL by day one, with a BG≤of 150 achieved in 67% of patients by day two of therapy. Twenty-two percent of patients suffered a hypoglycemic event (BG<60), reportedly similar to prior studies of insulin use in ICU and non-ICU settings. Eighty-two percent of patients received some form of nutritional support while on CII. In multivariate analyses, receiving oral nutrition (either a solid or liquid diet) was the only factor associated with increased risk of hyperglycemia and hypoglycemia.
This study was limited by its retrospective analysis in a single center. No comparison was made with basal-bolus or sliding-scale insulin therapy regarding efficacy or safety.
Bottom line: Non-ICU patients with hyperglycemia who received CII were able to achieve effective glycemic control within 48 hours of initiation, with rates of hypoglycemia comparable to those observed in ICU settings.
Citation: Smiley D, Rhee M, Peng L, et al. Safety and efficacy of continuous insulin infusion in noncritical care settings. J Hosp Med. 2010;5(4):212-217.
Hospitalists Spend More Time on Indirect, Rather Than Direct, Patient Care
Clinical question: What are the components of the daily workflow of hospitalists working on a non-housestaff service?
Background: The use of hospitalists is associated with increased efficiency in the hospital setting. However, it is not known how this efficiency is achieved. Prior literature has attempted to address this question, but with increasing demands and patient census, the representativeness of existing data is unclear.
Study design: Observational time-motion study.
Setting: Urban tertiary-care academic medical center.
Synopsis: Twenty-four hospitalists were directly observed for two weekday shifts. An electronic collection tool was developed using initial data on hospitalist activities and piloted prior to formal study data collection. Direct patient care was defined as involving face-to-face interaction between hospitalist and patient, while indirect patient care involved activities relevant to patient care but not performed in the patient’s presence.
Approximately 500 hours of observation were collected. Direct patient care comprised only a mean of 17.4% of the hospitalists’ daily workflow, while more was spent on indirect care, mainly electronic health record (EHR) documentation (mean 34.1%) and communication activities (mean 25.9%). Multitasking occurred 16% of the time, typically during communication or “critical documentation activities” (e.g. writing prescriptions). As patient volume increased, less time was spent in communication, and documentation was deferred to after hours.
These results were consistent with prior observational studies but were limited to a single center and might not represent the workflow of hospitalists in other settings, such as community hospitals, or nocturnists.
Bottom line: Hospitalists on non-housestaff services spend most of their time on indirect patient care and, with increasing patient census, communication is sacrificed. Multitasking is common during periods of communication and critical documentation.
Citation: Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go?—a time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.
Patients Who Leave Against Medical Advice Have Higher Readmission, Mortality Rates
Clinical question: What are the 30-day hospital readmission and mortality rates for Veterans Administration (VA) patients discharged against medical advice (AMA) compared with those appropriately discharged from the hospital?
Background: Patients discharged AMA might be at increased risk of experiencing worse outcomes. Small studies have demonstrated that patients with asthma and acute myocardial infarction (MI) discharged AMA have increased risk of readmission and death. However, it is unclear whether these risks are generalizable to a wider medical population.
Study design: Five-year retrospective cohort study.
Setting: One hundred twenty-nine VA acute-care hospitals.
Synopsis: Of the nearly 2 million patients admitted to the VA from 2004 to 2008, 1.7% were discharged AMA. Patients discharged AMA generally were younger, had lower incomes, and were more likely to be black. Furthermore, patients discharged AMA had statistically significant higher rates of 30-day readmission (17.7% vs. 11%, P<0.001) and higher 30-day mortality rates (0.75% vs. 0.61%, P=0.001) compared with those who had been appropriately discharged. In hazard models, discharge AMA was a significant predictor of 30-day readmission and conferred a nonstatistically significant increase in 30-day mortality.
Because all patients were seen in VA facilities, the results might not be generalizable to other acute-care settings. Although VA patients differ from the general medical population, the characteristics of patients discharged AMA are similar to those in previously published studies. The study utilized administrative data, which are very reliable but limited by little information on clinical factors that could contribute to AMA discharges.
Bottom line: Patients discharged AMA are at increased risk of worse post-hospitalization outcomes, including hospital readmission and death.
Citation: Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9): 926-929.
Simple Model Predicts Hospital Readmission
Clinical question: Which patient-level factors can be used in a simple model to predict hospital readmission of medicine patients?
Background: Hospital readmissions are common and costly. Previously published readmission prediction models have had limited utility because they focused on a specific condition, setting, or population, or were too cumbersome for practical use.
Study design: Prospective observational cohort study.
Setting: Six academic medical centers.
Synopsis: Data from nearly 11,000 general medicine patients were included in the analysis. Overall, almost 18% of patients were readmitted within 30 days of discharge.
In the prediction model derived and validated from the data, seven factors were significant predictors of readmission within 30 days of discharge: insurance status, marital status, having a regular healthcare provider, Charlson comorbidity index, SF 12 physical component score, one or more admissions within the last year, and current length of stay greater than two days. Points assigned from each significant predictor were used to create a risk score. The 5% of patients with risk scores of 25 and higher had 30-day readmission rates of approximately 30%, compared to readmission rates of approximately 16% in patients with scores of less than 25.
These results might not be generalizable to small, rural, nonacademic settings. Planned admissions could not be excluded from the data, and readmissions to nonstudy hospitals could not be ascertained. Despite these limitations, this model is easier to use than prior models and relevant to a broad population of patients.
Bottom line: A simple prediction model using patient-level factors can be used to identify patients at higher risk of readmission within 30 days of discharge to home.
Citation: Hasan O, Meltzer DO, Shaykevich SA, et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211-219.
No Difference in Outcomes Between High- and Non-High-Dose Proton Pump Inhibitors in Bleeding Peptic Ulcers
Clinical question: Do high-dose proton pump inhibitors (PPIs) decrease the rate of rebleeding, surgical intervention, or mortality in patients with bleeding peptic ulcers who have undergone endoscopic treatment?
Background: Previous studies have demonstrated superiority of both high- and low-dose PPIs to H2 receptor antagonists and placebo in reducing rebleeding rates in patients with peptic ulcers. However, no clear evidence is available to suggest that high-dose PPIs are more effective than non-high-dose PPIs for treatment of bleeding peptic ulcers.
Study design: Systematic review and meta-analysis.
Setting: Multicenter and single-site studies conducted in several countries.
Synopsis: Studies were included if they were randomized controlled trials, compared high- versus non-high-dose PPIs, evaluated endoscopically confirmed bleeding ulcers, gave PPIs after endoscopy, and documented outcomes regarding rates of rebleeding, surgical intervention, or mortality. High-dose PPIs were defined as equivalent to omeprazole 80 mg intravenous bolus followed by continuous intravenous infusion at 8 mg/hr for 72 hours.
Seven studies met inclusion criteria. The pooled odds ratios for rebleeding, surgical intervention, and mortality were 1.30 (95% CI, 0.88-1.91), 1.49 (95% CI, 0.66-3.37), and 0.89 (95% CI, 0.37-2.13), respectively, for high-dose versus non-high-dose PPIs. The authors concluded that high-dose PPIs were not superior to non-high-dose PPIs in reducing the rates of these adverse outcomes after endoscopic treatment of bleeding ulcers. Considering the cost of high-dose PPIs, further studies are indicated to help guide PPI dosing for patients with peptic ulcers.
Major limitations of this study were the small number of studies (1,157 patients in total) and their heterogeneity, and the lack of intention-to-treat analysis. The studies also included a high Asian predominance, and it has been shown that Asian populations have an enhanced PPI effect.
Bottom line: High-dose PPIs did not demonstrate reduced rates of ulcer rebleeding, surgical intervention, or mortality compared with non-high-dose PPIs in this meta-analysis, which included a small number of studies and patients.
Citation: Wang CH, Ma MH, Chou HC, et al. High-dose vs. non-high-dose proton pump inhibitors after endoscopic treatment in patients with bleeding peptic ulcer: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2010;170(9):751-758.
Hospital Utilization by Practicing Generalists Declined before the Emergence of Hospitalists
Clinical question: What has been the pattern of hospital utilization by generalists before and after the emergence of hospitalists?
Background: It has been proposed that the emergence of hospitalists has “crowded out” generalist physicians from the U.S. hospital setting. This study evaluated the trends of inpatient practice by generalists both before and after the emergence of hospitalists.
Study design: Retrospective analysis of national databases.
Setting: U.S. data from 1980 to 2005.
Synopsis: Utilizing the National Hospital Discharge Survey and the American Medical Association’s Physician Characteristics and Distribution in the U.S., information was extracted to evaluate the average number of annual inpatient encounters relative to generalist workforce from 1980 to 2005. Total inpatient encounters for each year were calculated by multiplying the total number of hospital admissions by the average hospital length of stay. The emergence of hospitalists was defined as beginning in 1994.
Total inpatient encounters by generalists declined by 35% in the pre-hospitalist era but remained essentially unchanged in the hospitalist era. During the pre-hospitalist period, the number of generalists doubled, to more than 200,000 from approximately 100,000, while the number of hospital discharges remained relatively stable and the length of stay declined by a third. The decrease in average inpatient encounters in the pre-hospitalist era is thought to have been secondary to decreased length of stay and increased workforce.
Bottom line: Hospital utilization relative to generalist physician workforce was decreasing prior to the emergence of hospitalists mainly due to decreased length of hospital stay and increased numbers of physicians.
Citation: Meltzer DO, Chung JW. U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists. J Gen Intern Med. 2010;25(5):453-459.
Fragmentation of Hospitalist Care Is Associated with Increased Length of Stay
Clinical question: Does fragmentation of care (FOC) by hospitalists affect length of stay (LOS)?
Background: Previous investigations have explored the impact of FOC provided by residency programs on LOS and quality of care. Results of these studies have been mixed. However, there have been no prior studies on the impact of the fragmentation of hospitalist care on LOS.
Study design: Concurrent control study.
Setting: Hospitalist practices all over the country managed by IPC: The Hospitalist Company.
Synopsis: Investigators looked at 10,977 patients admitted with diagnoses of pneumonia or heart failure. The primary endpoint was LOS. The independent variable of interest was a measure of FOC. The FOC was calculated as a quantitative index, by determining the percentage of hospitalist care delivered by a physician other than the primary hospitalist.
Multivariable analyses revealed a statistically significant increase in LOS of 0.39 days for each 10% increase in fragmentation level for pneumonia admissions. Similarly, for patients with heart failure, there was a significant increase in LOS of 0.30 days for each 10% increase in fragmentation level.
The study is a concurrent control study, so conclusions cannot be drawn about causality. Additionally, there are likely unmeasured differences between every hospital and hospitalist practice, which could further confound the relationships between hospitalist care and LOS.
Bottom line: Fragmentation of care provided by hospitalists is associated with an increased LOS in patients hospitalized for pneumonia or heart failure.
Citation: Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5(6):335-338.
Admission Medication Errors Are Common and Most Harmful in Older Patients Taking Many Medications
Clinical question: What are the risk factors and potential harm associated with medication errors at hospital admission?
Background: Obtaining a medication history from a hospitalized patient is an error-prone process. Several variables can affect the completeness and quality of medication histories, but existing data are limited regarding patient or medication risk factors associated with medication errors at admission.
Study design: Prospective cohort study.
Setting: Academic hospital in Chicago.
Synopsis: Pharmacist and admitting physician medication histories were compared with admission medication orders to identify any unexplained discrepancies. Discrepancies resulting in order changes were defined as medication errors.
Of the 651 adult medical inpatients studied, 234 (35.9%) had medication order errors identified at admission. Errors originated in the medication histories for 85% of these patients. The most frequent type of error was an omission (48.9%). An age of 65 or older (odds ratio [OR]=2.17, 95% confidence interval [CI], 1.09-4.30) and increased number of medications (OR=1.21, 95% CI, 1.14-1.29) were the only risk factors identified by multivariate analysis to be independently associated with increased risk of medication order errors potentially causing harm or requiring monitoring or intervention. Presenting a medication list upon admission was a significant protective factor (OR=0.35, 95% CI, 0.19-0.63).
Though this is the largest study to date evaluating admission medication errors in hospitalized medical patients, it remains limited by its single hospital site. Because the authors were unable to interview patients who were too ill or unwilling to participate and had no caregiver present, they might have underestimated the number of admission errors. Further, the harm assessment was based on potential and not actual harm.
Bottom line: Admission medication order errors are frequent, most commonly originate in the medication histories, and have increased potential to cause adverse outcomes in older patients and those taking higher numbers of medications.
Citation: Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447.
In This Edition
Literature at a Glance
A guide to this month’s studies
- Continuous insulin infusion in non-ICU patients
- How hospitalists spend their day
- Outcomes of patients leaving against medical advice
- Prediction rule for readmission
- Effects of high- vs. low-dose PPIs for peptic ulcer
- Hospital utilization by generalists before hospitalists
- Effect of hospitalist fragmentation on length of stay
- Medication errors at admissions in older patients
Continuous Insulin Infusion Provides Effective Glycemic Control in Non-ICU Patients
Clinical question: Is continuous insulin infusion (CII) a safe and effective option in the management of hyperglycemia in non-ICU patients?
Background: Hyperglycemia has been associated with worse outcomes in hospitalized patients. Prior research has demonstrated the benefit of CII in managing hyperglycemia in the ICU setting. However, outcomes have not been evaluated in the general medical (non-ICU) setting, where hyperglycemia is often inadequately addressed.
Study design: Retrospective chart review.
Setting: Urban tertiary-care medical center.
Synopsis: Charts of 200 adult patients treated with CII in non-ICU areas were reviewed with the primary outcomes including mean daily blood glucose (BG) levels and number of hyper- and hypoglycemic events occurring on CII. Mean BG dropped from 323 mg/dL to 182 mg/dL by day one, with a BG≤of 150 achieved in 67% of patients by day two of therapy. Twenty-two percent of patients suffered a hypoglycemic event (BG<60), reportedly similar to prior studies of insulin use in ICU and non-ICU settings. Eighty-two percent of patients received some form of nutritional support while on CII. In multivariate analyses, receiving oral nutrition (either a solid or liquid diet) was the only factor associated with increased risk of hyperglycemia and hypoglycemia.
This study was limited by its retrospective analysis in a single center. No comparison was made with basal-bolus or sliding-scale insulin therapy regarding efficacy or safety.
Bottom line: Non-ICU patients with hyperglycemia who received CII were able to achieve effective glycemic control within 48 hours of initiation, with rates of hypoglycemia comparable to those observed in ICU settings.
Citation: Smiley D, Rhee M, Peng L, et al. Safety and efficacy of continuous insulin infusion in noncritical care settings. J Hosp Med. 2010;5(4):212-217.
Hospitalists Spend More Time on Indirect, Rather Than Direct, Patient Care
Clinical question: What are the components of the daily workflow of hospitalists working on a non-housestaff service?
Background: The use of hospitalists is associated with increased efficiency in the hospital setting. However, it is not known how this efficiency is achieved. Prior literature has attempted to address this question, but with increasing demands and patient census, the representativeness of existing data is unclear.
Study design: Observational time-motion study.
Setting: Urban tertiary-care academic medical center.
Synopsis: Twenty-four hospitalists were directly observed for two weekday shifts. An electronic collection tool was developed using initial data on hospitalist activities and piloted prior to formal study data collection. Direct patient care was defined as involving face-to-face interaction between hospitalist and patient, while indirect patient care involved activities relevant to patient care but not performed in the patient’s presence.
Approximately 500 hours of observation were collected. Direct patient care comprised only a mean of 17.4% of the hospitalists’ daily workflow, while more was spent on indirect care, mainly electronic health record (EHR) documentation (mean 34.1%) and communication activities (mean 25.9%). Multitasking occurred 16% of the time, typically during communication or “critical documentation activities” (e.g. writing prescriptions). As patient volume increased, less time was spent in communication, and documentation was deferred to after hours.
These results were consistent with prior observational studies but were limited to a single center and might not represent the workflow of hospitalists in other settings, such as community hospitals, or nocturnists.
Bottom line: Hospitalists on non-housestaff services spend most of their time on indirect patient care and, with increasing patient census, communication is sacrificed. Multitasking is common during periods of communication and critical documentation.
Citation: Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go?—a time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.
Patients Who Leave Against Medical Advice Have Higher Readmission, Mortality Rates
Clinical question: What are the 30-day hospital readmission and mortality rates for Veterans Administration (VA) patients discharged against medical advice (AMA) compared with those appropriately discharged from the hospital?
Background: Patients discharged AMA might be at increased risk of experiencing worse outcomes. Small studies have demonstrated that patients with asthma and acute myocardial infarction (MI) discharged AMA have increased risk of readmission and death. However, it is unclear whether these risks are generalizable to a wider medical population.
Study design: Five-year retrospective cohort study.
Setting: One hundred twenty-nine VA acute-care hospitals.
Synopsis: Of the nearly 2 million patients admitted to the VA from 2004 to 2008, 1.7% were discharged AMA. Patients discharged AMA generally were younger, had lower incomes, and were more likely to be black. Furthermore, patients discharged AMA had statistically significant higher rates of 30-day readmission (17.7% vs. 11%, P<0.001) and higher 30-day mortality rates (0.75% vs. 0.61%, P=0.001) compared with those who had been appropriately discharged. In hazard models, discharge AMA was a significant predictor of 30-day readmission and conferred a nonstatistically significant increase in 30-day mortality.
Because all patients were seen in VA facilities, the results might not be generalizable to other acute-care settings. Although VA patients differ from the general medical population, the characteristics of patients discharged AMA are similar to those in previously published studies. The study utilized administrative data, which are very reliable but limited by little information on clinical factors that could contribute to AMA discharges.
Bottom line: Patients discharged AMA are at increased risk of worse post-hospitalization outcomes, including hospital readmission and death.
Citation: Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9): 926-929.
Simple Model Predicts Hospital Readmission
Clinical question: Which patient-level factors can be used in a simple model to predict hospital readmission of medicine patients?
Background: Hospital readmissions are common and costly. Previously published readmission prediction models have had limited utility because they focused on a specific condition, setting, or population, or were too cumbersome for practical use.
Study design: Prospective observational cohort study.
Setting: Six academic medical centers.
Synopsis: Data from nearly 11,000 general medicine patients were included in the analysis. Overall, almost 18% of patients were readmitted within 30 days of discharge.
In the prediction model derived and validated from the data, seven factors were significant predictors of readmission within 30 days of discharge: insurance status, marital status, having a regular healthcare provider, Charlson comorbidity index, SF 12 physical component score, one or more admissions within the last year, and current length of stay greater than two days. Points assigned from each significant predictor were used to create a risk score. The 5% of patients with risk scores of 25 and higher had 30-day readmission rates of approximately 30%, compared to readmission rates of approximately 16% in patients with scores of less than 25.
These results might not be generalizable to small, rural, nonacademic settings. Planned admissions could not be excluded from the data, and readmissions to nonstudy hospitals could not be ascertained. Despite these limitations, this model is easier to use than prior models and relevant to a broad population of patients.
Bottom line: A simple prediction model using patient-level factors can be used to identify patients at higher risk of readmission within 30 days of discharge to home.
Citation: Hasan O, Meltzer DO, Shaykevich SA, et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211-219.
No Difference in Outcomes Between High- and Non-High-Dose Proton Pump Inhibitors in Bleeding Peptic Ulcers
Clinical question: Do high-dose proton pump inhibitors (PPIs) decrease the rate of rebleeding, surgical intervention, or mortality in patients with bleeding peptic ulcers who have undergone endoscopic treatment?
Background: Previous studies have demonstrated superiority of both high- and low-dose PPIs to H2 receptor antagonists and placebo in reducing rebleeding rates in patients with peptic ulcers. However, no clear evidence is available to suggest that high-dose PPIs are more effective than non-high-dose PPIs for treatment of bleeding peptic ulcers.
Study design: Systematic review and meta-analysis.
Setting: Multicenter and single-site studies conducted in several countries.
Synopsis: Studies were included if they were randomized controlled trials, compared high- versus non-high-dose PPIs, evaluated endoscopically confirmed bleeding ulcers, gave PPIs after endoscopy, and documented outcomes regarding rates of rebleeding, surgical intervention, or mortality. High-dose PPIs were defined as equivalent to omeprazole 80 mg intravenous bolus followed by continuous intravenous infusion at 8 mg/hr for 72 hours.
Seven studies met inclusion criteria. The pooled odds ratios for rebleeding, surgical intervention, and mortality were 1.30 (95% CI, 0.88-1.91), 1.49 (95% CI, 0.66-3.37), and 0.89 (95% CI, 0.37-2.13), respectively, for high-dose versus non-high-dose PPIs. The authors concluded that high-dose PPIs were not superior to non-high-dose PPIs in reducing the rates of these adverse outcomes after endoscopic treatment of bleeding ulcers. Considering the cost of high-dose PPIs, further studies are indicated to help guide PPI dosing for patients with peptic ulcers.
Major limitations of this study were the small number of studies (1,157 patients in total) and their heterogeneity, and the lack of intention-to-treat analysis. The studies also included a high Asian predominance, and it has been shown that Asian populations have an enhanced PPI effect.
Bottom line: High-dose PPIs did not demonstrate reduced rates of ulcer rebleeding, surgical intervention, or mortality compared with non-high-dose PPIs in this meta-analysis, which included a small number of studies and patients.
Citation: Wang CH, Ma MH, Chou HC, et al. High-dose vs. non-high-dose proton pump inhibitors after endoscopic treatment in patients with bleeding peptic ulcer: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2010;170(9):751-758.
Hospital Utilization by Practicing Generalists Declined before the Emergence of Hospitalists
Clinical question: What has been the pattern of hospital utilization by generalists before and after the emergence of hospitalists?
Background: It has been proposed that the emergence of hospitalists has “crowded out” generalist physicians from the U.S. hospital setting. This study evaluated the trends of inpatient practice by generalists both before and after the emergence of hospitalists.
Study design: Retrospective analysis of national databases.
Setting: U.S. data from 1980 to 2005.
Synopsis: Utilizing the National Hospital Discharge Survey and the American Medical Association’s Physician Characteristics and Distribution in the U.S., information was extracted to evaluate the average number of annual inpatient encounters relative to generalist workforce from 1980 to 2005. Total inpatient encounters for each year were calculated by multiplying the total number of hospital admissions by the average hospital length of stay. The emergence of hospitalists was defined as beginning in 1994.
Total inpatient encounters by generalists declined by 35% in the pre-hospitalist era but remained essentially unchanged in the hospitalist era. During the pre-hospitalist period, the number of generalists doubled, to more than 200,000 from approximately 100,000, while the number of hospital discharges remained relatively stable and the length of stay declined by a third. The decrease in average inpatient encounters in the pre-hospitalist era is thought to have been secondary to decreased length of stay and increased workforce.
Bottom line: Hospital utilization relative to generalist physician workforce was decreasing prior to the emergence of hospitalists mainly due to decreased length of hospital stay and increased numbers of physicians.
Citation: Meltzer DO, Chung JW. U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists. J Gen Intern Med. 2010;25(5):453-459.
Fragmentation of Hospitalist Care Is Associated with Increased Length of Stay
Clinical question: Does fragmentation of care (FOC) by hospitalists affect length of stay (LOS)?
Background: Previous investigations have explored the impact of FOC provided by residency programs on LOS and quality of care. Results of these studies have been mixed. However, there have been no prior studies on the impact of the fragmentation of hospitalist care on LOS.
Study design: Concurrent control study.
Setting: Hospitalist practices all over the country managed by IPC: The Hospitalist Company.
Synopsis: Investigators looked at 10,977 patients admitted with diagnoses of pneumonia or heart failure. The primary endpoint was LOS. The independent variable of interest was a measure of FOC. The FOC was calculated as a quantitative index, by determining the percentage of hospitalist care delivered by a physician other than the primary hospitalist.
Multivariable analyses revealed a statistically significant increase in LOS of 0.39 days for each 10% increase in fragmentation level for pneumonia admissions. Similarly, for patients with heart failure, there was a significant increase in LOS of 0.30 days for each 10% increase in fragmentation level.
The study is a concurrent control study, so conclusions cannot be drawn about causality. Additionally, there are likely unmeasured differences between every hospital and hospitalist practice, which could further confound the relationships between hospitalist care and LOS.
Bottom line: Fragmentation of care provided by hospitalists is associated with an increased LOS in patients hospitalized for pneumonia or heart failure.
Citation: Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5(6):335-338.
Admission Medication Errors Are Common and Most Harmful in Older Patients Taking Many Medications
Clinical question: What are the risk factors and potential harm associated with medication errors at hospital admission?
Background: Obtaining a medication history from a hospitalized patient is an error-prone process. Several variables can affect the completeness and quality of medication histories, but existing data are limited regarding patient or medication risk factors associated with medication errors at admission.
Study design: Prospective cohort study.
Setting: Academic hospital in Chicago.
Synopsis: Pharmacist and admitting physician medication histories were compared with admission medication orders to identify any unexplained discrepancies. Discrepancies resulting in order changes were defined as medication errors.
Of the 651 adult medical inpatients studied, 234 (35.9%) had medication order errors identified at admission. Errors originated in the medication histories for 85% of these patients. The most frequent type of error was an omission (48.9%). An age of 65 or older (odds ratio [OR]=2.17, 95% confidence interval [CI], 1.09-4.30) and increased number of medications (OR=1.21, 95% CI, 1.14-1.29) were the only risk factors identified by multivariate analysis to be independently associated with increased risk of medication order errors potentially causing harm or requiring monitoring or intervention. Presenting a medication list upon admission was a significant protective factor (OR=0.35, 95% CI, 0.19-0.63).
Though this is the largest study to date evaluating admission medication errors in hospitalized medical patients, it remains limited by its single hospital site. Because the authors were unable to interview patients who were too ill or unwilling to participate and had no caregiver present, they might have underestimated the number of admission errors. Further, the harm assessment was based on potential and not actual harm.
Bottom line: Admission medication order errors are frequent, most commonly originate in the medication histories, and have increased potential to cause adverse outcomes in older patients and those taking higher numbers of medications.
Citation: Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447.
Pediatric HM Literature Review
Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?
Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.
Study design: Retrospective cohort study.
Setting: Twenty-four freestanding children’s hospitals.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.
More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.
Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.
A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.
Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.
Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.
Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?
Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.
Study design: Retrospective cohort study.
Setting: Twenty-four freestanding children’s hospitals.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.
More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.
Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.
A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.
Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.
Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.
Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?
Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.
Study design: Retrospective cohort study.
Setting: Twenty-four freestanding children’s hospitals.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.
More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.
Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.
A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.
Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.
Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.
Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Market Watch
New Generics
- Atomoxetine capsules (Strattera)1
- Clonidine transdermal system USP (catapres-TTS)2
- Enoxaparin sodium injection (Lovenox)3
- Naratriptan hydrochloride 2.5-mg tablets (Amerge)4
New Drugs, Devices, Indications, and Dosage Forms
- A combination tablet containing both aliskiren and amlodipine (Tekamlo) has been approved by the FDA for the treatment of hypertension (HTN).5 Four strengths for once-daily dosing are available.
- Antihemophilic factor VIII (recombinant) injection (Xyntha) for treatment of hemophilia A has been approved by the FDA in a pre-filled, dual-chamber syringe for intravenous (IV) infusion following reconstitution of the freeze-dried powder with 0.9% sodium chloride diluent (both supplied in the dosage form).6 The first dose will be available in the 3,000 international units strength (4 mL). Other dosages will be available in 2011.
- Bimatoprost ophthalmic solution 0.01% (Lumigan) has been approved by the FDA as a first-line treatment for reducing intraocular pressure in patients with open-angle glaucoma or ocular hypertension.7
- Buprenorphine/naloxone sublingual film (Suboxone sublingual) has been approved by the FDA for the treatment of opioid dependence.8
- Coagulation factor VIIa room temperature stable (recombinant) (NovoSeven RT) has been approved by the FDA in an 8-mg vial.9 This larger size allows rapid initiation and administration of this product for patients who need a larger dose. Additionally, this product is approved for an extended shelf life, for all vial sizes, to 36 months at room temperature.
- Donepezil 21-mg tablets (Aricept) have been approved by the FDA for the treatment of moderate to severe Alzheimer’s disease.10
- Glycopyrrolate cherry-flavored oral solution (Cuvposa) has been approved by the FDA as an orphan drug for treating chronic severe drooling in patients ages 3 to 16 with neurological conditions such as cerebral palsy.11
- Immune globulin subcutaneous (human) 20% liquid (Hizentra) has been approved by the FDA for a 24-month shelf life at room temperature when protected from light.12
- Miconazole 50-mg buccal tablets (Oravig) have been approved by the FDA to topically treat oropharyngeal candidiasis in patients 16 and older.13
- Niacin extended release/simvastatin tablets (Simcor) have been approved by the FDA in two new dosage strengths: 500 mg/40 mg and 1000 mg/40 mg.14
- Olmesartan medoxomil, amlodipine besylate, and hydrochlorothiazide tablets (HCTZ) (Tribenzor) have been approved by the FDA in a single tablet to treat hypertension (not initial therapy).15 This combination should not be used in patients with a creatinine clearance <30 mL/minute, or in patients with renal artery stenosis.
- STX-100 has received orphan drug status for treating idiopathic pulmonary fibrosis (IPF) for which there currently are no FDA-approved treatments.16 STX-100 is a humanized, monoclonal antibody that targets integrin vb6, which exhibited major antifibrotic activity in preclinical animal models of the lung and other organs. The FDA previously granted orphan drug designation for STX-100 for chronic allograft nephropathy. A Phase 2 trial in IPF is planned for 2011.
- Docetaxel injection concentrate (Taxotere) has been approved by the FDA in a one-vial system, which eliminates the dilution step.17
- Valganciclovir injection (Valcyte) is FDA-approved for an increased therapy length (200 days) in adult renal transplant patients at high risk of developing cytomegalovirus disease (CMV).18 This extends the length of therapy from 100 days.
Safety, Warnings, and Label Changes
- Carbidopa/levodopa and entacapone tablets (Stalevo) are undergoing a safety review in relation to a possible increased cardiovascular event risk, including myocardial infarction, stroke, and cardiovascular death, compared with patients only taking carbidopa/levodopa.19 An FDA meta-analysis of 15 clinical trials found a small increased risk of cardiovascular events. However, this meta-analysis was not specifically designed to assess cardiovascular safety, and most patients had pre-existing cardiovascular disease risk factors, so even small differences in the level of these risks could significantly affect the study outcomes. Additionally, most negative cardiovascular events occurred in a single trial. The FDA recommends regular evaluation of patients’ cardiovascular status.
- Tigecycline IV injection (Tygacil) has undergone a label change in its “Warnings” and “Precautions” in relation to an increased mortality risk.20 A pooled analysis compared tigecycline use to other similar antibacterials for managing different serious infections. Patients who had a greater increased risk of death were those with hospital-acquired pneumonia, ventilator-associated pneumonia, complicated skin and skin structure infections, diabetic foot infections, and complicated intra-abdominal infections.
Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.
References
- Actavis receives FDA approval of atomoxetine HCI capsules. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/199692.php. Accessed Sept. 2, 2010.
- Mylan receives approval for generic version of Catapres-TTS. Mylan Inc. website. Available at: http://investor.mylan.com/releasedetail.cfm?ReleaseID=489338. Accessed July 20, 2010.
- Riley K. FDA approves first generic enoxaparin sodium injection. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm220092.htm. Accessed Sept. 13, 2010.
- First-time generic approvals August 2010. Formulary website. Available at: http://formularyjournal.modernmedicine.com/formulary/Modern+Medicine+Now/First-time-generic-approvals-Aug.-2010/ArticleStandard/Article/detail/683182?contextCategoryId=44276. Accessed Sept. 7, 2010.
- Novartis receives FDA approval of Tekamlo, a single-pill combination of aliskiren and amlodipine to treat high blood pressure. Novartis Pharmaceuticals Corporation website. Available at: http://www.pharma.us.novartis.com/info/newsroom/press-release.jsp?PRID=2286. Accessed Sept. 13, 2010.
- Xyntha prefilled dual-chamber syringe approved for hemophilia A treatment. Monthly Prescribing Reference website. Available at: http://www.empr.com/xyntha-pre-filled-dual-chamber-syringe-approved-for-hemophilia-a-treatment/article/176666/. Accessed Aug.18, 2010.
- Allergan, Inc. receives FDA approval for Lumigan 0.01% as first-line therapy indicated for the reduction of elevated intraocular pressure in glaucoma patients. MarketWatch website. Available at: http://www.marketwatch.com/story/allergan-inc-receives-fda-approval-for-lumiganr-001-as-first-line-therapy-indicated-for-the-reduction-of-elevated-intraocular-pressure-in-glaucoma-patients-2010-08-31?reflink=MW_news_stmp. Accessed Sept. 2, 2010.
- MonoSol Rx announces Reckitt Benckiser FDA approval of Suboxone sublingual film for treatment of opioid dependence. PR Newswire website. Available at: http://www.prnewswire.com/news-releases/monosol-rx-announces-reckitt-benckiser-fda-approval-of-suboxone-sublingual-film-for-treatment-of-opioid-dependence-101874388.html. Accessed Sept. 14, 2010.
- NovoSeven RT 8mg vial approved for hemophilia A or B. Monthly Prescribing Reference website. Available at: http://www.empr.com/novoseven-rt-8mg-vial-approved-for-hemophilia-a-or-b/printarticle/176743/. Accessed Sept. 13, 2010.
- Eisai announces U.S. FDA approval for new higher dose Aricept 23 mg tablet for the treatment of moderate-to-severe Alzheimer’s disease. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/196410.php. Accessed Sept. 13, 2010.
- Cuvposa approved for chronic severe drooling associated with neurologic conditions. Monthly Prescribing Reference website. Available at: http://www.empr.com/cuvposa-approved-for-chronic-severe-drooling-associated-with-neurologic-conditions/article/175824/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Aug. 2, 2010.
- Shelf life of Hizentra extended from 18 to 24 months. Monthly Prescribing Reference website. Available at: http://www.empr.com/shelf-life-of-hizentra-extended-from-18-to-24-months/article/177068/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Aug. 23, 2010.
- Oravig available for oropharyngeal candidiasis. Monthly Prescribing Reference website. Available at: http://www.empr.com/oravig-available-for-oropharyngeal-candidiasis/article/177492/. Accessed Sept. 13, 2010.
- Additional dosage strengths of Simcor approved. Monthly Prescribing Reference website. Available at: http://www.empr.com/additional-dosage-strengths-of-simcor-approved/article/175825/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Sept. 13, 2010.
- Tribenzor 20/5/12.5mg. Monthly Prescribing Reference website. Available at: http://www.empr.com/tribenzor-205125mg/drugproduct/129/. Accessed Sept. 13, 2010.
- Stromedix receives FDA orphan drug designation for STX-100 for the treatment of idiopathic pulmonary fibrosis. Stromedix website. Available at: http://www.stromedix.com/Stromedix_STX-100_Orphan_Drug_IPF.pdf. Accessed Sept. 13, 2010.
- Dane L. Sanofi-Aventis garners FDA approval for one-vial formulation of Taxotere. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E0B4E517F06C4A9E94DC88EADBA079A8. Accessed Sept. 13, 2010.
- FDA approves longer use of Valcyte for adult kidney transplant patients at high risk of developing cytomegalovirus (CMV) disease. Genentech website. Available at: http://www.gene.com/gene/news/press-releases/display.do?method=detail&id=12907. Accessed Sept. 13, 2010.
- FDA drug safety communication: ongoing safety review of Stalevo and possible increased cardiovascular risk. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm223060.htm. Accessed Sept. 13, 2010.
- FDA drug safety communication: increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm224370.htm. Accessed Sept. 13, 2010.
New Generics
- Atomoxetine capsules (Strattera)1
- Clonidine transdermal system USP (catapres-TTS)2
- Enoxaparin sodium injection (Lovenox)3
- Naratriptan hydrochloride 2.5-mg tablets (Amerge)4
New Drugs, Devices, Indications, and Dosage Forms
- A combination tablet containing both aliskiren and amlodipine (Tekamlo) has been approved by the FDA for the treatment of hypertension (HTN).5 Four strengths for once-daily dosing are available.
- Antihemophilic factor VIII (recombinant) injection (Xyntha) for treatment of hemophilia A has been approved by the FDA in a pre-filled, dual-chamber syringe for intravenous (IV) infusion following reconstitution of the freeze-dried powder with 0.9% sodium chloride diluent (both supplied in the dosage form).6 The first dose will be available in the 3,000 international units strength (4 mL). Other dosages will be available in 2011.
- Bimatoprost ophthalmic solution 0.01% (Lumigan) has been approved by the FDA as a first-line treatment for reducing intraocular pressure in patients with open-angle glaucoma or ocular hypertension.7
- Buprenorphine/naloxone sublingual film (Suboxone sublingual) has been approved by the FDA for the treatment of opioid dependence.8
- Coagulation factor VIIa room temperature stable (recombinant) (NovoSeven RT) has been approved by the FDA in an 8-mg vial.9 This larger size allows rapid initiation and administration of this product for patients who need a larger dose. Additionally, this product is approved for an extended shelf life, for all vial sizes, to 36 months at room temperature.
- Donepezil 21-mg tablets (Aricept) have been approved by the FDA for the treatment of moderate to severe Alzheimer’s disease.10
- Glycopyrrolate cherry-flavored oral solution (Cuvposa) has been approved by the FDA as an orphan drug for treating chronic severe drooling in patients ages 3 to 16 with neurological conditions such as cerebral palsy.11
- Immune globulin subcutaneous (human) 20% liquid (Hizentra) has been approved by the FDA for a 24-month shelf life at room temperature when protected from light.12
- Miconazole 50-mg buccal tablets (Oravig) have been approved by the FDA to topically treat oropharyngeal candidiasis in patients 16 and older.13
- Niacin extended release/simvastatin tablets (Simcor) have been approved by the FDA in two new dosage strengths: 500 mg/40 mg and 1000 mg/40 mg.14
- Olmesartan medoxomil, amlodipine besylate, and hydrochlorothiazide tablets (HCTZ) (Tribenzor) have been approved by the FDA in a single tablet to treat hypertension (not initial therapy).15 This combination should not be used in patients with a creatinine clearance <30 mL/minute, or in patients with renal artery stenosis.
- STX-100 has received orphan drug status for treating idiopathic pulmonary fibrosis (IPF) for which there currently are no FDA-approved treatments.16 STX-100 is a humanized, monoclonal antibody that targets integrin vb6, which exhibited major antifibrotic activity in preclinical animal models of the lung and other organs. The FDA previously granted orphan drug designation for STX-100 for chronic allograft nephropathy. A Phase 2 trial in IPF is planned for 2011.
- Docetaxel injection concentrate (Taxotere) has been approved by the FDA in a one-vial system, which eliminates the dilution step.17
- Valganciclovir injection (Valcyte) is FDA-approved for an increased therapy length (200 days) in adult renal transplant patients at high risk of developing cytomegalovirus disease (CMV).18 This extends the length of therapy from 100 days.
Safety, Warnings, and Label Changes
- Carbidopa/levodopa and entacapone tablets (Stalevo) are undergoing a safety review in relation to a possible increased cardiovascular event risk, including myocardial infarction, stroke, and cardiovascular death, compared with patients only taking carbidopa/levodopa.19 An FDA meta-analysis of 15 clinical trials found a small increased risk of cardiovascular events. However, this meta-analysis was not specifically designed to assess cardiovascular safety, and most patients had pre-existing cardiovascular disease risk factors, so even small differences in the level of these risks could significantly affect the study outcomes. Additionally, most negative cardiovascular events occurred in a single trial. The FDA recommends regular evaluation of patients’ cardiovascular status.
- Tigecycline IV injection (Tygacil) has undergone a label change in its “Warnings” and “Precautions” in relation to an increased mortality risk.20 A pooled analysis compared tigecycline use to other similar antibacterials for managing different serious infections. Patients who had a greater increased risk of death were those with hospital-acquired pneumonia, ventilator-associated pneumonia, complicated skin and skin structure infections, diabetic foot infections, and complicated intra-abdominal infections.
Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.
References
- Actavis receives FDA approval of atomoxetine HCI capsules. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/199692.php. Accessed Sept. 2, 2010.
- Mylan receives approval for generic version of Catapres-TTS. Mylan Inc. website. Available at: http://investor.mylan.com/releasedetail.cfm?ReleaseID=489338. Accessed July 20, 2010.
- Riley K. FDA approves first generic enoxaparin sodium injection. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm220092.htm. Accessed Sept. 13, 2010.
- First-time generic approvals August 2010. Formulary website. Available at: http://formularyjournal.modernmedicine.com/formulary/Modern+Medicine+Now/First-time-generic-approvals-Aug.-2010/ArticleStandard/Article/detail/683182?contextCategoryId=44276. Accessed Sept. 7, 2010.
- Novartis receives FDA approval of Tekamlo, a single-pill combination of aliskiren and amlodipine to treat high blood pressure. Novartis Pharmaceuticals Corporation website. Available at: http://www.pharma.us.novartis.com/info/newsroom/press-release.jsp?PRID=2286. Accessed Sept. 13, 2010.
- Xyntha prefilled dual-chamber syringe approved for hemophilia A treatment. Monthly Prescribing Reference website. Available at: http://www.empr.com/xyntha-pre-filled-dual-chamber-syringe-approved-for-hemophilia-a-treatment/article/176666/. Accessed Aug.18, 2010.
- Allergan, Inc. receives FDA approval for Lumigan 0.01% as first-line therapy indicated for the reduction of elevated intraocular pressure in glaucoma patients. MarketWatch website. Available at: http://www.marketwatch.com/story/allergan-inc-receives-fda-approval-for-lumiganr-001-as-first-line-therapy-indicated-for-the-reduction-of-elevated-intraocular-pressure-in-glaucoma-patients-2010-08-31?reflink=MW_news_stmp. Accessed Sept. 2, 2010.
- MonoSol Rx announces Reckitt Benckiser FDA approval of Suboxone sublingual film for treatment of opioid dependence. PR Newswire website. Available at: http://www.prnewswire.com/news-releases/monosol-rx-announces-reckitt-benckiser-fda-approval-of-suboxone-sublingual-film-for-treatment-of-opioid-dependence-101874388.html. Accessed Sept. 14, 2010.
- NovoSeven RT 8mg vial approved for hemophilia A or B. Monthly Prescribing Reference website. Available at: http://www.empr.com/novoseven-rt-8mg-vial-approved-for-hemophilia-a-or-b/printarticle/176743/. Accessed Sept. 13, 2010.
- Eisai announces U.S. FDA approval for new higher dose Aricept 23 mg tablet for the treatment of moderate-to-severe Alzheimer’s disease. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/196410.php. Accessed Sept. 13, 2010.
- Cuvposa approved for chronic severe drooling associated with neurologic conditions. Monthly Prescribing Reference website. Available at: http://www.empr.com/cuvposa-approved-for-chronic-severe-drooling-associated-with-neurologic-conditions/article/175824/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Aug. 2, 2010.
- Shelf life of Hizentra extended from 18 to 24 months. Monthly Prescribing Reference website. Available at: http://www.empr.com/shelf-life-of-hizentra-extended-from-18-to-24-months/article/177068/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Aug. 23, 2010.
- Oravig available for oropharyngeal candidiasis. Monthly Prescribing Reference website. Available at: http://www.empr.com/oravig-available-for-oropharyngeal-candidiasis/article/177492/. Accessed Sept. 13, 2010.
- Additional dosage strengths of Simcor approved. Monthly Prescribing Reference website. Available at: http://www.empr.com/additional-dosage-strengths-of-simcor-approved/article/175825/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Sept. 13, 2010.
- Tribenzor 20/5/12.5mg. Monthly Prescribing Reference website. Available at: http://www.empr.com/tribenzor-205125mg/drugproduct/129/. Accessed Sept. 13, 2010.
- Stromedix receives FDA orphan drug designation for STX-100 for the treatment of idiopathic pulmonary fibrosis. Stromedix website. Available at: http://www.stromedix.com/Stromedix_STX-100_Orphan_Drug_IPF.pdf. Accessed Sept. 13, 2010.
- Dane L. Sanofi-Aventis garners FDA approval for one-vial formulation of Taxotere. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E0B4E517F06C4A9E94DC88EADBA079A8. Accessed Sept. 13, 2010.
- FDA approves longer use of Valcyte for adult kidney transplant patients at high risk of developing cytomegalovirus (CMV) disease. Genentech website. Available at: http://www.gene.com/gene/news/press-releases/display.do?method=detail&id=12907. Accessed Sept. 13, 2010.
- FDA drug safety communication: ongoing safety review of Stalevo and possible increased cardiovascular risk. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm223060.htm. Accessed Sept. 13, 2010.
- FDA drug safety communication: increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm224370.htm. Accessed Sept. 13, 2010.
New Generics
- Atomoxetine capsules (Strattera)1
- Clonidine transdermal system USP (catapres-TTS)2
- Enoxaparin sodium injection (Lovenox)3
- Naratriptan hydrochloride 2.5-mg tablets (Amerge)4
New Drugs, Devices, Indications, and Dosage Forms
- A combination tablet containing both aliskiren and amlodipine (Tekamlo) has been approved by the FDA for the treatment of hypertension (HTN).5 Four strengths for once-daily dosing are available.
- Antihemophilic factor VIII (recombinant) injection (Xyntha) for treatment of hemophilia A has been approved by the FDA in a pre-filled, dual-chamber syringe for intravenous (IV) infusion following reconstitution of the freeze-dried powder with 0.9% sodium chloride diluent (both supplied in the dosage form).6 The first dose will be available in the 3,000 international units strength (4 mL). Other dosages will be available in 2011.
- Bimatoprost ophthalmic solution 0.01% (Lumigan) has been approved by the FDA as a first-line treatment for reducing intraocular pressure in patients with open-angle glaucoma or ocular hypertension.7
- Buprenorphine/naloxone sublingual film (Suboxone sublingual) has been approved by the FDA for the treatment of opioid dependence.8
- Coagulation factor VIIa room temperature stable (recombinant) (NovoSeven RT) has been approved by the FDA in an 8-mg vial.9 This larger size allows rapid initiation and administration of this product for patients who need a larger dose. Additionally, this product is approved for an extended shelf life, for all vial sizes, to 36 months at room temperature.
- Donepezil 21-mg tablets (Aricept) have been approved by the FDA for the treatment of moderate to severe Alzheimer’s disease.10
- Glycopyrrolate cherry-flavored oral solution (Cuvposa) has been approved by the FDA as an orphan drug for treating chronic severe drooling in patients ages 3 to 16 with neurological conditions such as cerebral palsy.11
- Immune globulin subcutaneous (human) 20% liquid (Hizentra) has been approved by the FDA for a 24-month shelf life at room temperature when protected from light.12
- Miconazole 50-mg buccal tablets (Oravig) have been approved by the FDA to topically treat oropharyngeal candidiasis in patients 16 and older.13
- Niacin extended release/simvastatin tablets (Simcor) have been approved by the FDA in two new dosage strengths: 500 mg/40 mg and 1000 mg/40 mg.14
- Olmesartan medoxomil, amlodipine besylate, and hydrochlorothiazide tablets (HCTZ) (Tribenzor) have been approved by the FDA in a single tablet to treat hypertension (not initial therapy).15 This combination should not be used in patients with a creatinine clearance <30 mL/minute, or in patients with renal artery stenosis.
- STX-100 has received orphan drug status for treating idiopathic pulmonary fibrosis (IPF) for which there currently are no FDA-approved treatments.16 STX-100 is a humanized, monoclonal antibody that targets integrin vb6, which exhibited major antifibrotic activity in preclinical animal models of the lung and other organs. The FDA previously granted orphan drug designation for STX-100 for chronic allograft nephropathy. A Phase 2 trial in IPF is planned for 2011.
- Docetaxel injection concentrate (Taxotere) has been approved by the FDA in a one-vial system, which eliminates the dilution step.17
- Valganciclovir injection (Valcyte) is FDA-approved for an increased therapy length (200 days) in adult renal transplant patients at high risk of developing cytomegalovirus disease (CMV).18 This extends the length of therapy from 100 days.
Safety, Warnings, and Label Changes
- Carbidopa/levodopa and entacapone tablets (Stalevo) are undergoing a safety review in relation to a possible increased cardiovascular event risk, including myocardial infarction, stroke, and cardiovascular death, compared with patients only taking carbidopa/levodopa.19 An FDA meta-analysis of 15 clinical trials found a small increased risk of cardiovascular events. However, this meta-analysis was not specifically designed to assess cardiovascular safety, and most patients had pre-existing cardiovascular disease risk factors, so even small differences in the level of these risks could significantly affect the study outcomes. Additionally, most negative cardiovascular events occurred in a single trial. The FDA recommends regular evaluation of patients’ cardiovascular status.
- Tigecycline IV injection (Tygacil) has undergone a label change in its “Warnings” and “Precautions” in relation to an increased mortality risk.20 A pooled analysis compared tigecycline use to other similar antibacterials for managing different serious infections. Patients who had a greater increased risk of death were those with hospital-acquired pneumonia, ventilator-associated pneumonia, complicated skin and skin structure infections, diabetic foot infections, and complicated intra-abdominal infections.
Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.
References
- Actavis receives FDA approval of atomoxetine HCI capsules. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/199692.php. Accessed Sept. 2, 2010.
- Mylan receives approval for generic version of Catapres-TTS. Mylan Inc. website. Available at: http://investor.mylan.com/releasedetail.cfm?ReleaseID=489338. Accessed July 20, 2010.
- Riley K. FDA approves first generic enoxaparin sodium injection. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm220092.htm. Accessed Sept. 13, 2010.
- First-time generic approvals August 2010. Formulary website. Available at: http://formularyjournal.modernmedicine.com/formulary/Modern+Medicine+Now/First-time-generic-approvals-Aug.-2010/ArticleStandard/Article/detail/683182?contextCategoryId=44276. Accessed Sept. 7, 2010.
- Novartis receives FDA approval of Tekamlo, a single-pill combination of aliskiren and amlodipine to treat high blood pressure. Novartis Pharmaceuticals Corporation website. Available at: http://www.pharma.us.novartis.com/info/newsroom/press-release.jsp?PRID=2286. Accessed Sept. 13, 2010.
- Xyntha prefilled dual-chamber syringe approved for hemophilia A treatment. Monthly Prescribing Reference website. Available at: http://www.empr.com/xyntha-pre-filled-dual-chamber-syringe-approved-for-hemophilia-a-treatment/article/176666/. Accessed Aug.18, 2010.
- Allergan, Inc. receives FDA approval for Lumigan 0.01% as first-line therapy indicated for the reduction of elevated intraocular pressure in glaucoma patients. MarketWatch website. Available at: http://www.marketwatch.com/story/allergan-inc-receives-fda-approval-for-lumiganr-001-as-first-line-therapy-indicated-for-the-reduction-of-elevated-intraocular-pressure-in-glaucoma-patients-2010-08-31?reflink=MW_news_stmp. Accessed Sept. 2, 2010.
- MonoSol Rx announces Reckitt Benckiser FDA approval of Suboxone sublingual film for treatment of opioid dependence. PR Newswire website. Available at: http://www.prnewswire.com/news-releases/monosol-rx-announces-reckitt-benckiser-fda-approval-of-suboxone-sublingual-film-for-treatment-of-opioid-dependence-101874388.html. Accessed Sept. 14, 2010.
- NovoSeven RT 8mg vial approved for hemophilia A or B. Monthly Prescribing Reference website. Available at: http://www.empr.com/novoseven-rt-8mg-vial-approved-for-hemophilia-a-or-b/printarticle/176743/. Accessed Sept. 13, 2010.
- Eisai announces U.S. FDA approval for new higher dose Aricept 23 mg tablet for the treatment of moderate-to-severe Alzheimer’s disease. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/196410.php. Accessed Sept. 13, 2010.
- Cuvposa approved for chronic severe drooling associated with neurologic conditions. Monthly Prescribing Reference website. Available at: http://www.empr.com/cuvposa-approved-for-chronic-severe-drooling-associated-with-neurologic-conditions/article/175824/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Aug. 2, 2010.
- Shelf life of Hizentra extended from 18 to 24 months. Monthly Prescribing Reference website. Available at: http://www.empr.com/shelf-life-of-hizentra-extended-from-18-to-24-months/article/177068/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Aug. 23, 2010.
- Oravig available for oropharyngeal candidiasis. Monthly Prescribing Reference website. Available at: http://www.empr.com/oravig-available-for-oropharyngeal-candidiasis/article/177492/. Accessed Sept. 13, 2010.
- Additional dosage strengths of Simcor approved. Monthly Prescribing Reference website. Available at: http://www.empr.com/additional-dosage-strengths-of-simcor-approved/article/175825/?DCMP=EMC-MPR_WeeklyNewsbrief. Accessed Sept. 13, 2010.
- Tribenzor 20/5/12.5mg. Monthly Prescribing Reference website. Available at: http://www.empr.com/tribenzor-205125mg/drugproduct/129/. Accessed Sept. 13, 2010.
- Stromedix receives FDA orphan drug designation for STX-100 for the treatment of idiopathic pulmonary fibrosis. Stromedix website. Available at: http://www.stromedix.com/Stromedix_STX-100_Orphan_Drug_IPF.pdf. Accessed Sept. 13, 2010.
- Dane L. Sanofi-Aventis garners FDA approval for one-vial formulation of Taxotere. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E0B4E517F06C4A9E94DC88EADBA079A8. Accessed Sept. 13, 2010.
- FDA approves longer use of Valcyte for adult kidney transplant patients at high risk of developing cytomegalovirus (CMV) disease. Genentech website. Available at: http://www.gene.com/gene/news/press-releases/display.do?method=detail&id=12907. Accessed Sept. 13, 2010.
- FDA drug safety communication: ongoing safety review of Stalevo and possible increased cardiovascular risk. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm223060.htm. Accessed Sept. 13, 2010.
- FDA drug safety communication: increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm224370.htm. Accessed Sept. 13, 2010.