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Split Personality
By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.
But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.
Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.
Academia Fosters Cooperation—and Lack Thereof
An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.
“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.
“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”
Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.
“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”
For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:
- Typically more hospitalists in each department, leading to greater scheduling flexibility;
- Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
- The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.
Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.
As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.
Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.
“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”
“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”
The Community Setting: Challenges and Successes
Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.
“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”
In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.
That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.
Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.
“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”
In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.
“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.
Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.
“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.
But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.
As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.
Building the Perfect Beast
So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.
In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.
“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”
When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.
“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”
Call Protection
As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.
“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”
Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”
Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.
Back Where You Belong
Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.
If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.
Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.
Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.
It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.
“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”
As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.
Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.
“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”
The Future of Med-Ped Hospitalists
At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?
“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.
It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.
And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH
Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.
By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.
But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.
Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.
Academia Fosters Cooperation—and Lack Thereof
An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.
“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.
“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”
Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.
“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”
For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:
- Typically more hospitalists in each department, leading to greater scheduling flexibility;
- Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
- The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.
Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.
As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.
Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.
“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”
“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”
The Community Setting: Challenges and Successes
Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.
“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”
In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.
That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.
Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.
“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”
In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.
“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.
Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.
“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.
But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.
As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.
Building the Perfect Beast
So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.
In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.
“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”
When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.
“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”
Call Protection
As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.
“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”
Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”
Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.
Back Where You Belong
Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.
If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.
Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.
Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.
It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.
“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”
As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.
Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.
“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”
The Future of Med-Ped Hospitalists
At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?
“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.
It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.
And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH
Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.
By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.
But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.
Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.
Academia Fosters Cooperation—and Lack Thereof
An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.
“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.
“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”
Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.
“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”
For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:
- Typically more hospitalists in each department, leading to greater scheduling flexibility;
- Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
- The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.
Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.
As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.
Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.
“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”
“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”
The Community Setting: Challenges and Successes
Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.
“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”
In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.
That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.
Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.
“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”
In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.
“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.
Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.
“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.
But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.
As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.
Building the Perfect Beast
So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.
In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.
“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”
When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.
“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”
Call Protection
As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.
“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”
Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”
Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.
Back Where You Belong
Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.
If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.
Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.
Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.
It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.
“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”
As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.
Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.
“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”
The Future of Med-Ped Hospitalists
At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?
“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.
It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.
And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH
Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.
A Bundle of Nerves
In a single year, one health system saved itself more than $2 million on orthopedic, cardiology, and cardiovascular surgery procedures. Another hospital saved Medicare an estimated $750,000. Supply costs dropped, scores on quality metrics rose, and bonus payments were distributed to participating doctors.
A runaway success? Not so fast.
Encouraging, if early, results from Medicare’s Acute Care Episode (ACE) Demonstration might have strengthened the case for bundling payments around episodes of care as an effective way to rein in spiraling healthcare costs and transition from a volume-based to a value-based payment system. But broad skepticism persists over the wisdom of binding together the fates of hospitals and doctors, and critics are far from ready to drop their argument that bundling will be unworkable across wider, less-well-defined swaths of healthcare.
The current bundling and gain-sharing duo differs only superficially from the despised capitation model of the 1990s, argues Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company. “It’s capitation in a different dress, except that instead of over a patient population, it’s done over an individual patient’s case,” he says.
Not so, says Lisa Kettering, MD, SFHM, vice president of medical affairs and CMO at Exempla St. Joseph Hospital in Denver.
“I’ve been around in medicine long enough to have been around when there was capitation,” she says. “I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.”
Amid the swirling expectations and apprehensions, what has the ACE demo taught us so far about bundling, and what does it mean for the future of hospital medicine? In essence, bundling lumps Medicare Part A and Part B reimbursements into a single payment aimed at encouraging hospitals and doctors to work together to improve efficiency, maintain high-quality care, and reduce overall expenses. Hospitals participating in the ACE Demonstration provide a roughly 5% discount to Medicare for a specific list of diagnosis-related groups (DRGs), and the Centers for Medicare & Medicaid Services (CMS) passes on half of the savings to beneficiaries who use participating hospitals for the covered procedures.
After submitting their claims, the hospitals receive a bundled Medicare payment, from which they pay doctors 100% of their Part B fees. As an incentive, some providers are eligible for bonus payments in the form of gain-sharing. CMS rules preclude any payments for referrals, cap all payments at 25% of the physician fee schedule, and mandate that any payment be based on reductions in patient care costs due to ACE activities. But participating hospitals are otherwise free to devise their own formulas and specific quality metrics that doctors must meet to gain the bonus.
SHM repeatedly has signaled its support for exploring bundling as a way to better align financial incentives among providers and reward them for quality and efficiency instead of quantity. The 10,000-member society strongly supports further testing of payment bundling methodologies prior to a national rollout, however, and has called for the integral involvement of hospitalists in developing and implementing bundling projects.
With its main focus on cardiologists, orthopedic surgeons, and cardiovascular surgeons, the ACE Demonstration has had little direct impact on hospitalists’ jobs or bank accounts—so far. That could change with an expanded pilot mandated by healthcare reform legislation. Slated to begin by Jan. 1, 2013, the project will redefine covered episodes of care to include all medical services administered three days before a hospital admission through 30 days after discharge.
CMS hasn’t yet decided which procedures will be covered, but officials say they’ve learned from past experience to begin with well-defined episodes of care. “Back in the ’90s, we did a bundled demonstration for bypass procedures and also for cataract procedures,” says Cynthia Mason, project manager with the CMS Medicare Demonstrations Group. “What we learned from that is obviously it’s easier both for Medicare, as well as for the providers, to predict utilization when you have a more standardized package of services. You also need a variety and large number of services in order to give you opportunities for looking at efficiencies and improvements in the system.”
Upfront Investment, Immediate Savings, Improved Quality
Early opinions have been mostly positive among the ACE participants. Hillcrest Medical Center in Tulsa, Okla., was first out of the gate in May 2009. Over the project’s first year, Hillcrest CEO Steve Dobbs estimates that the 490-bed hospital has saved CMS about $750,000; half of that sum has been passed along to patients. The hospital itself has spent about $550,000 in marketing, start-up costs, corporate support, and paying third-party claims. But recent investments have led to double-digit gains in patient volume (24% in cardiology and cardiovascular surgery, and a whopping 37% in orthopedics), margins in orthopedics are up, and direct negotiations between participating doctors and national vendors have netted additional savings. As a reward for help with cost-cutting, Hillcrest recently passed along two gain-sharing checks totaling $130,000 to be split among six independent orthopedists.
“What’s actually driving this program is the supply cost savings from all of our national partners,” Dobbs says. A big question is whether the negotiated savings—and hence the gain-sharing—could be maintained over a greatly expanded pilot project. “If this goes nationwide and everybody’s in it, do you get the same benefit? I don’t know the answer to that right now,” he says.
Dobbs is careful to point out that success is not measured by patient volume and supply costs alone. Hillcrest’s gain-sharing plan stipulates that physicians must reach the 90% threshold for a range of quality metrics. For one previously problematic category—stopping antibiotics 24 hours post-surgery—Dobbs says both the orthopedics and cardiovascular surgery departments have dramatically increased their compliance rates.
Baptist Health System in San Antonio, which began its own demonstration in June 2009, has reported savings of $2.2 million for its 1,275-bed, four-campus health system. So far, the roughly 20 hospitalists employed by IPC: The Hospitalist Company who work within the Baptist Health System have not directly participated in the project. But Felix Aguirre, MD, FHM, IPC’s vice president of medical affairs in San Antonio, says the demonstration has had a definite impact on efficiency.
“Since the demonstration project has come up, it seems like everybody is obeying the evidence-based guidelines now,” says Dr. Aguirre, a member of SHM’s Public Policy Committee and Team Hospitalist. “So it’s not keeping the hip replacement patient in for five days, it’s what the guidelines say: three days.”
Some kinks still need to be worked out. Baptist has had trouble with double payments and other claims-related issues, Dr. Aguirre says. Hillcrest’s Dobbs complains that he has heard virtually no feedback from CMS. Medicare’s Mason says officials have been “very pleased” with the project’s progress so far, but concedes that a delay in updating a claims processing system has pushed back the launch at two other demonstration sites until Nov. 1.
At one of those sites, 361-bed Exempla St. Joseph Hospital, the three-year demonstration will encompass only cardiology and cardiovascular surgery. Dr. Kettering, a former SHM board member who serves as executive sponsor and director of St. Joseph Hospital’s ACE demo, says the shared-savings program will be limited to cardiovascular surgery for the first year to ensure the system is running smoothly. In the second or third year, however, hospitalists who care for eligible patients could theoretically benefit from a similar gain-sharing agreement, if they meet certain agreed-upon, evidence-based metrics. In that circumstance, she says, hospitalists would begin to learn the ropes and become directly involved in quality outcomes. Extending the model beyond ACE, their primary role could expand dramatically to that of learning how to operate bundling across the continuum of care.
The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.
All Eggs in One Basket?
One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.
If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.
Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.
Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.
HM: Front and Center
Hospitalists might be uniquely well positioned to bring more efficiency and value, as well as help hospitals manage that risk. With bundling, though, the big question is how they’ll be paid for their services amid the demands of multiple providers. “I’ve heard it described as a big potential food fight,” says Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Workforce Summit Committee.
In the scenario relayed to him by fearful hospitalists, a hospital administrator is seated at the table with pie in hand, with the various providers clamoring for a slice. “Everyone will be sitting there saying, ‘Here’s why we deserve this percent of the bundled payment,’” Mathews says. “Whether that’s an accurate portrayal or not, that’s the fear.”
Taken a step further, the scenario envisions hospitalists struggling to hold their own at the table against high-powered and higher-paid specialists. Some of the ACE Demonstration sites, however, have used physician-hospital organizations, or PHOs, to help decentralize the decision-making and ensure that stakeholders are represented. Similarly, if patient referrals to hospitalists from other providers drop—as they did for some of the ACE Demonstration bundles at Baptist and Hillcrest—could hospitalists lose their bargaining power through an erosion of recouped professional fees?
If bundling expands, Hillcrest’s CEO says hospitalists are instead likely to assume a more central role (see “Six Pieces of Bundling-Related Advice for Hospitalists,” right). “If we truly go to bundled payments on everything,” Dobbs says, “then I think everybody’s got to be at the table and contributing, and especially the hospitalist, because the medical DRGs, that’s going to be where the hospitalists drive the equation, and that’s going to be a huge part of this.”
As SHM’s CEO Larry Wellikson, MD, SFHM, wrote in The Hospitalist last year (see “Bundling Bedlam,” July 2009, p. 46), the bundling of Medicare Part A dollars that subsidize HM with Part B physicians’ payments might actually pave the way for a more professional discussion of the value that hospitalists deliver. With bundling, he wrote, “the need for subsidies or support could diminish or vanish.”
But that doesn’t resolve the issue of how to fairly size each bundle. Stuart Guterman, vice president of the Washington, D.C.-based Common-wealth Fund’s Program on Payment and System Reform, says one lesson from the capitation scheme of the ’90s is that an overemphasis on cost savings can lead to payments that are frequently insufficient to cover the costs of appropriate care.
“So there’s got to be more collaboration on what an appropriate amount is, and that’s a very important feature,” Guterman says. “Clearly, if you don’t pay enough, it doesn’t bode well for the success of any kind of payment approach. If you pay too much, it means you’re wasting money.”
The size and complexity of healthcare networks will influence how those bundle-related payments are negotiated. And in this case, several analysts say bigger isn’t necessarily better. “My own view is that it’s easier for a handful of hospitalists and a few community doctors in the hospital to come to an agreement on how they’re going to work within a bundle,” says Robert Berenson, MD, a senior fellow in the Urban Institute’s Health Policy Center and vice chair of the Medicare Payment Advisory Commission (MedPAC).
“My experience is that in rural communities, there’s a greater alliance of interests between the doctors and the hospitals, whereas in big urban areas they’re often competing with each other. So I don’t see that as the problem, frankly. I think this is probably better designed for smaller places where there’s already reasonably good relationships.”
L. Scott Sussman, MD, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, Vt., agrees that bundling likely wouldn’t negatively affect the day-to-day operations of the 25-bed critical-access hospital. Almost all admitted patients have PCPs in the affiliated Mt. Ascutney Physicians Practice, aiding communication during hospitalizations and care transitions. Dr. Sussman thinks bundling fits well with the mission of hospitalists to provide quality care and help smooth their patients’ transition back to community providers. “From the reading that I’ve done on bundling, it does seem to me that if implemented properly, it really could achieve cost savings while maintaining quality care,” he says.
Nevertheless, he has plenty of questions and concerns. Bundling would be more complicated, he concedes, if most admissions were referred from private-practice physicians in the community. And because Mt. Ascutney is a critical-access hospital, patients who develop complications or require a higher level of care are transferred to a tertiary-care facility—in this case, a 22-mile drive over the state line to Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “How would the payment be divided up at that point?” he asks.
To make bundling work, healthcare leaders will clearly need to blaze a trail through uncharted territory.
But if the goal is getting more from the trillions spent annually on healthcare, advocates like Guterman say it provides an important step toward a better-functioning system.
Among hospitalists, at least some observers are betting that bundling will ultimately find its way. “I think bundled payments are here to stay,” Dr. Aguirre says. “I think our goal now is to see how we can modify it or create it so it can have the best impact for us and we can have the best impact for it.” TH
Bryn Nelson is a freelance medical writer based in Seattle.
In a single year, one health system saved itself more than $2 million on orthopedic, cardiology, and cardiovascular surgery procedures. Another hospital saved Medicare an estimated $750,000. Supply costs dropped, scores on quality metrics rose, and bonus payments were distributed to participating doctors.
A runaway success? Not so fast.
Encouraging, if early, results from Medicare’s Acute Care Episode (ACE) Demonstration might have strengthened the case for bundling payments around episodes of care as an effective way to rein in spiraling healthcare costs and transition from a volume-based to a value-based payment system. But broad skepticism persists over the wisdom of binding together the fates of hospitals and doctors, and critics are far from ready to drop their argument that bundling will be unworkable across wider, less-well-defined swaths of healthcare.
The current bundling and gain-sharing duo differs only superficially from the despised capitation model of the 1990s, argues Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company. “It’s capitation in a different dress, except that instead of over a patient population, it’s done over an individual patient’s case,” he says.
Not so, says Lisa Kettering, MD, SFHM, vice president of medical affairs and CMO at Exempla St. Joseph Hospital in Denver.
“I’ve been around in medicine long enough to have been around when there was capitation,” she says. “I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.”
Amid the swirling expectations and apprehensions, what has the ACE demo taught us so far about bundling, and what does it mean for the future of hospital medicine? In essence, bundling lumps Medicare Part A and Part B reimbursements into a single payment aimed at encouraging hospitals and doctors to work together to improve efficiency, maintain high-quality care, and reduce overall expenses. Hospitals participating in the ACE Demonstration provide a roughly 5% discount to Medicare for a specific list of diagnosis-related groups (DRGs), and the Centers for Medicare & Medicaid Services (CMS) passes on half of the savings to beneficiaries who use participating hospitals for the covered procedures.
After submitting their claims, the hospitals receive a bundled Medicare payment, from which they pay doctors 100% of their Part B fees. As an incentive, some providers are eligible for bonus payments in the form of gain-sharing. CMS rules preclude any payments for referrals, cap all payments at 25% of the physician fee schedule, and mandate that any payment be based on reductions in patient care costs due to ACE activities. But participating hospitals are otherwise free to devise their own formulas and specific quality metrics that doctors must meet to gain the bonus.
SHM repeatedly has signaled its support for exploring bundling as a way to better align financial incentives among providers and reward them for quality and efficiency instead of quantity. The 10,000-member society strongly supports further testing of payment bundling methodologies prior to a national rollout, however, and has called for the integral involvement of hospitalists in developing and implementing bundling projects.
With its main focus on cardiologists, orthopedic surgeons, and cardiovascular surgeons, the ACE Demonstration has had little direct impact on hospitalists’ jobs or bank accounts—so far. That could change with an expanded pilot mandated by healthcare reform legislation. Slated to begin by Jan. 1, 2013, the project will redefine covered episodes of care to include all medical services administered three days before a hospital admission through 30 days after discharge.
CMS hasn’t yet decided which procedures will be covered, but officials say they’ve learned from past experience to begin with well-defined episodes of care. “Back in the ’90s, we did a bundled demonstration for bypass procedures and also for cataract procedures,” says Cynthia Mason, project manager with the CMS Medicare Demonstrations Group. “What we learned from that is obviously it’s easier both for Medicare, as well as for the providers, to predict utilization when you have a more standardized package of services. You also need a variety and large number of services in order to give you opportunities for looking at efficiencies and improvements in the system.”
Upfront Investment, Immediate Savings, Improved Quality
Early opinions have been mostly positive among the ACE participants. Hillcrest Medical Center in Tulsa, Okla., was first out of the gate in May 2009. Over the project’s first year, Hillcrest CEO Steve Dobbs estimates that the 490-bed hospital has saved CMS about $750,000; half of that sum has been passed along to patients. The hospital itself has spent about $550,000 in marketing, start-up costs, corporate support, and paying third-party claims. But recent investments have led to double-digit gains in patient volume (24% in cardiology and cardiovascular surgery, and a whopping 37% in orthopedics), margins in orthopedics are up, and direct negotiations between participating doctors and national vendors have netted additional savings. As a reward for help with cost-cutting, Hillcrest recently passed along two gain-sharing checks totaling $130,000 to be split among six independent orthopedists.
“What’s actually driving this program is the supply cost savings from all of our national partners,” Dobbs says. A big question is whether the negotiated savings—and hence the gain-sharing—could be maintained over a greatly expanded pilot project. “If this goes nationwide and everybody’s in it, do you get the same benefit? I don’t know the answer to that right now,” he says.
Dobbs is careful to point out that success is not measured by patient volume and supply costs alone. Hillcrest’s gain-sharing plan stipulates that physicians must reach the 90% threshold for a range of quality metrics. For one previously problematic category—stopping antibiotics 24 hours post-surgery—Dobbs says both the orthopedics and cardiovascular surgery departments have dramatically increased their compliance rates.
Baptist Health System in San Antonio, which began its own demonstration in June 2009, has reported savings of $2.2 million for its 1,275-bed, four-campus health system. So far, the roughly 20 hospitalists employed by IPC: The Hospitalist Company who work within the Baptist Health System have not directly participated in the project. But Felix Aguirre, MD, FHM, IPC’s vice president of medical affairs in San Antonio, says the demonstration has had a definite impact on efficiency.
“Since the demonstration project has come up, it seems like everybody is obeying the evidence-based guidelines now,” says Dr. Aguirre, a member of SHM’s Public Policy Committee and Team Hospitalist. “So it’s not keeping the hip replacement patient in for five days, it’s what the guidelines say: three days.”
Some kinks still need to be worked out. Baptist has had trouble with double payments and other claims-related issues, Dr. Aguirre says. Hillcrest’s Dobbs complains that he has heard virtually no feedback from CMS. Medicare’s Mason says officials have been “very pleased” with the project’s progress so far, but concedes that a delay in updating a claims processing system has pushed back the launch at two other demonstration sites until Nov. 1.
At one of those sites, 361-bed Exempla St. Joseph Hospital, the three-year demonstration will encompass only cardiology and cardiovascular surgery. Dr. Kettering, a former SHM board member who serves as executive sponsor and director of St. Joseph Hospital’s ACE demo, says the shared-savings program will be limited to cardiovascular surgery for the first year to ensure the system is running smoothly. In the second or third year, however, hospitalists who care for eligible patients could theoretically benefit from a similar gain-sharing agreement, if they meet certain agreed-upon, evidence-based metrics. In that circumstance, she says, hospitalists would begin to learn the ropes and become directly involved in quality outcomes. Extending the model beyond ACE, their primary role could expand dramatically to that of learning how to operate bundling across the continuum of care.
The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.
All Eggs in One Basket?
One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.
If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.
Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.
Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.
HM: Front and Center
Hospitalists might be uniquely well positioned to bring more efficiency and value, as well as help hospitals manage that risk. With bundling, though, the big question is how they’ll be paid for their services amid the demands of multiple providers. “I’ve heard it described as a big potential food fight,” says Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Workforce Summit Committee.
In the scenario relayed to him by fearful hospitalists, a hospital administrator is seated at the table with pie in hand, with the various providers clamoring for a slice. “Everyone will be sitting there saying, ‘Here’s why we deserve this percent of the bundled payment,’” Mathews says. “Whether that’s an accurate portrayal or not, that’s the fear.”
Taken a step further, the scenario envisions hospitalists struggling to hold their own at the table against high-powered and higher-paid specialists. Some of the ACE Demonstration sites, however, have used physician-hospital organizations, or PHOs, to help decentralize the decision-making and ensure that stakeholders are represented. Similarly, if patient referrals to hospitalists from other providers drop—as they did for some of the ACE Demonstration bundles at Baptist and Hillcrest—could hospitalists lose their bargaining power through an erosion of recouped professional fees?
If bundling expands, Hillcrest’s CEO says hospitalists are instead likely to assume a more central role (see “Six Pieces of Bundling-Related Advice for Hospitalists,” right). “If we truly go to bundled payments on everything,” Dobbs says, “then I think everybody’s got to be at the table and contributing, and especially the hospitalist, because the medical DRGs, that’s going to be where the hospitalists drive the equation, and that’s going to be a huge part of this.”
As SHM’s CEO Larry Wellikson, MD, SFHM, wrote in The Hospitalist last year (see “Bundling Bedlam,” July 2009, p. 46), the bundling of Medicare Part A dollars that subsidize HM with Part B physicians’ payments might actually pave the way for a more professional discussion of the value that hospitalists deliver. With bundling, he wrote, “the need for subsidies or support could diminish or vanish.”
But that doesn’t resolve the issue of how to fairly size each bundle. Stuart Guterman, vice president of the Washington, D.C.-based Common-wealth Fund’s Program on Payment and System Reform, says one lesson from the capitation scheme of the ’90s is that an overemphasis on cost savings can lead to payments that are frequently insufficient to cover the costs of appropriate care.
“So there’s got to be more collaboration on what an appropriate amount is, and that’s a very important feature,” Guterman says. “Clearly, if you don’t pay enough, it doesn’t bode well for the success of any kind of payment approach. If you pay too much, it means you’re wasting money.”
The size and complexity of healthcare networks will influence how those bundle-related payments are negotiated. And in this case, several analysts say bigger isn’t necessarily better. “My own view is that it’s easier for a handful of hospitalists and a few community doctors in the hospital to come to an agreement on how they’re going to work within a bundle,” says Robert Berenson, MD, a senior fellow in the Urban Institute’s Health Policy Center and vice chair of the Medicare Payment Advisory Commission (MedPAC).
“My experience is that in rural communities, there’s a greater alliance of interests between the doctors and the hospitals, whereas in big urban areas they’re often competing with each other. So I don’t see that as the problem, frankly. I think this is probably better designed for smaller places where there’s already reasonably good relationships.”
L. Scott Sussman, MD, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, Vt., agrees that bundling likely wouldn’t negatively affect the day-to-day operations of the 25-bed critical-access hospital. Almost all admitted patients have PCPs in the affiliated Mt. Ascutney Physicians Practice, aiding communication during hospitalizations and care transitions. Dr. Sussman thinks bundling fits well with the mission of hospitalists to provide quality care and help smooth their patients’ transition back to community providers. “From the reading that I’ve done on bundling, it does seem to me that if implemented properly, it really could achieve cost savings while maintaining quality care,” he says.
Nevertheless, he has plenty of questions and concerns. Bundling would be more complicated, he concedes, if most admissions were referred from private-practice physicians in the community. And because Mt. Ascutney is a critical-access hospital, patients who develop complications or require a higher level of care are transferred to a tertiary-care facility—in this case, a 22-mile drive over the state line to Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “How would the payment be divided up at that point?” he asks.
To make bundling work, healthcare leaders will clearly need to blaze a trail through uncharted territory.
But if the goal is getting more from the trillions spent annually on healthcare, advocates like Guterman say it provides an important step toward a better-functioning system.
Among hospitalists, at least some observers are betting that bundling will ultimately find its way. “I think bundled payments are here to stay,” Dr. Aguirre says. “I think our goal now is to see how we can modify it or create it so it can have the best impact for us and we can have the best impact for it.” TH
Bryn Nelson is a freelance medical writer based in Seattle.
In a single year, one health system saved itself more than $2 million on orthopedic, cardiology, and cardiovascular surgery procedures. Another hospital saved Medicare an estimated $750,000. Supply costs dropped, scores on quality metrics rose, and bonus payments were distributed to participating doctors.
A runaway success? Not so fast.
Encouraging, if early, results from Medicare’s Acute Care Episode (ACE) Demonstration might have strengthened the case for bundling payments around episodes of care as an effective way to rein in spiraling healthcare costs and transition from a volume-based to a value-based payment system. But broad skepticism persists over the wisdom of binding together the fates of hospitals and doctors, and critics are far from ready to drop their argument that bundling will be unworkable across wider, less-well-defined swaths of healthcare.
The current bundling and gain-sharing duo differs only superficially from the despised capitation model of the 1990s, argues Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company. “It’s capitation in a different dress, except that instead of over a patient population, it’s done over an individual patient’s case,” he says.
Not so, says Lisa Kettering, MD, SFHM, vice president of medical affairs and CMO at Exempla St. Joseph Hospital in Denver.
“I’ve been around in medicine long enough to have been around when there was capitation,” she says. “I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.”
Amid the swirling expectations and apprehensions, what has the ACE demo taught us so far about bundling, and what does it mean for the future of hospital medicine? In essence, bundling lumps Medicare Part A and Part B reimbursements into a single payment aimed at encouraging hospitals and doctors to work together to improve efficiency, maintain high-quality care, and reduce overall expenses. Hospitals participating in the ACE Demonstration provide a roughly 5% discount to Medicare for a specific list of diagnosis-related groups (DRGs), and the Centers for Medicare & Medicaid Services (CMS) passes on half of the savings to beneficiaries who use participating hospitals for the covered procedures.
After submitting their claims, the hospitals receive a bundled Medicare payment, from which they pay doctors 100% of their Part B fees. As an incentive, some providers are eligible for bonus payments in the form of gain-sharing. CMS rules preclude any payments for referrals, cap all payments at 25% of the physician fee schedule, and mandate that any payment be based on reductions in patient care costs due to ACE activities. But participating hospitals are otherwise free to devise their own formulas and specific quality metrics that doctors must meet to gain the bonus.
SHM repeatedly has signaled its support for exploring bundling as a way to better align financial incentives among providers and reward them for quality and efficiency instead of quantity. The 10,000-member society strongly supports further testing of payment bundling methodologies prior to a national rollout, however, and has called for the integral involvement of hospitalists in developing and implementing bundling projects.
With its main focus on cardiologists, orthopedic surgeons, and cardiovascular surgeons, the ACE Demonstration has had little direct impact on hospitalists’ jobs or bank accounts—so far. That could change with an expanded pilot mandated by healthcare reform legislation. Slated to begin by Jan. 1, 2013, the project will redefine covered episodes of care to include all medical services administered three days before a hospital admission through 30 days after discharge.
CMS hasn’t yet decided which procedures will be covered, but officials say they’ve learned from past experience to begin with well-defined episodes of care. “Back in the ’90s, we did a bundled demonstration for bypass procedures and also for cataract procedures,” says Cynthia Mason, project manager with the CMS Medicare Demonstrations Group. “What we learned from that is obviously it’s easier both for Medicare, as well as for the providers, to predict utilization when you have a more standardized package of services. You also need a variety and large number of services in order to give you opportunities for looking at efficiencies and improvements in the system.”
Upfront Investment, Immediate Savings, Improved Quality
Early opinions have been mostly positive among the ACE participants. Hillcrest Medical Center in Tulsa, Okla., was first out of the gate in May 2009. Over the project’s first year, Hillcrest CEO Steve Dobbs estimates that the 490-bed hospital has saved CMS about $750,000; half of that sum has been passed along to patients. The hospital itself has spent about $550,000 in marketing, start-up costs, corporate support, and paying third-party claims. But recent investments have led to double-digit gains in patient volume (24% in cardiology and cardiovascular surgery, and a whopping 37% in orthopedics), margins in orthopedics are up, and direct negotiations between participating doctors and national vendors have netted additional savings. As a reward for help with cost-cutting, Hillcrest recently passed along two gain-sharing checks totaling $130,000 to be split among six independent orthopedists.
“What’s actually driving this program is the supply cost savings from all of our national partners,” Dobbs says. A big question is whether the negotiated savings—and hence the gain-sharing—could be maintained over a greatly expanded pilot project. “If this goes nationwide and everybody’s in it, do you get the same benefit? I don’t know the answer to that right now,” he says.
Dobbs is careful to point out that success is not measured by patient volume and supply costs alone. Hillcrest’s gain-sharing plan stipulates that physicians must reach the 90% threshold for a range of quality metrics. For one previously problematic category—stopping antibiotics 24 hours post-surgery—Dobbs says both the orthopedics and cardiovascular surgery departments have dramatically increased their compliance rates.
Baptist Health System in San Antonio, which began its own demonstration in June 2009, has reported savings of $2.2 million for its 1,275-bed, four-campus health system. So far, the roughly 20 hospitalists employed by IPC: The Hospitalist Company who work within the Baptist Health System have not directly participated in the project. But Felix Aguirre, MD, FHM, IPC’s vice president of medical affairs in San Antonio, says the demonstration has had a definite impact on efficiency.
“Since the demonstration project has come up, it seems like everybody is obeying the evidence-based guidelines now,” says Dr. Aguirre, a member of SHM’s Public Policy Committee and Team Hospitalist. “So it’s not keeping the hip replacement patient in for five days, it’s what the guidelines say: three days.”
Some kinks still need to be worked out. Baptist has had trouble with double payments and other claims-related issues, Dr. Aguirre says. Hillcrest’s Dobbs complains that he has heard virtually no feedback from CMS. Medicare’s Mason says officials have been “very pleased” with the project’s progress so far, but concedes that a delay in updating a claims processing system has pushed back the launch at two other demonstration sites until Nov. 1.
At one of those sites, 361-bed Exempla St. Joseph Hospital, the three-year demonstration will encompass only cardiology and cardiovascular surgery. Dr. Kettering, a former SHM board member who serves as executive sponsor and director of St. Joseph Hospital’s ACE demo, says the shared-savings program will be limited to cardiovascular surgery for the first year to ensure the system is running smoothly. In the second or third year, however, hospitalists who care for eligible patients could theoretically benefit from a similar gain-sharing agreement, if they meet certain agreed-upon, evidence-based metrics. In that circumstance, she says, hospitalists would begin to learn the ropes and become directly involved in quality outcomes. Extending the model beyond ACE, their primary role could expand dramatically to that of learning how to operate bundling across the continuum of care.
The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.
All Eggs in One Basket?
One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.
If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.
Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.
Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.
HM: Front and Center
Hospitalists might be uniquely well positioned to bring more efficiency and value, as well as help hospitals manage that risk. With bundling, though, the big question is how they’ll be paid for their services amid the demands of multiple providers. “I’ve heard it described as a big potential food fight,” says Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Workforce Summit Committee.
In the scenario relayed to him by fearful hospitalists, a hospital administrator is seated at the table with pie in hand, with the various providers clamoring for a slice. “Everyone will be sitting there saying, ‘Here’s why we deserve this percent of the bundled payment,’” Mathews says. “Whether that’s an accurate portrayal or not, that’s the fear.”
Taken a step further, the scenario envisions hospitalists struggling to hold their own at the table against high-powered and higher-paid specialists. Some of the ACE Demonstration sites, however, have used physician-hospital organizations, or PHOs, to help decentralize the decision-making and ensure that stakeholders are represented. Similarly, if patient referrals to hospitalists from other providers drop—as they did for some of the ACE Demonstration bundles at Baptist and Hillcrest—could hospitalists lose their bargaining power through an erosion of recouped professional fees?
If bundling expands, Hillcrest’s CEO says hospitalists are instead likely to assume a more central role (see “Six Pieces of Bundling-Related Advice for Hospitalists,” right). “If we truly go to bundled payments on everything,” Dobbs says, “then I think everybody’s got to be at the table and contributing, and especially the hospitalist, because the medical DRGs, that’s going to be where the hospitalists drive the equation, and that’s going to be a huge part of this.”
As SHM’s CEO Larry Wellikson, MD, SFHM, wrote in The Hospitalist last year (see “Bundling Bedlam,” July 2009, p. 46), the bundling of Medicare Part A dollars that subsidize HM with Part B physicians’ payments might actually pave the way for a more professional discussion of the value that hospitalists deliver. With bundling, he wrote, “the need for subsidies or support could diminish or vanish.”
But that doesn’t resolve the issue of how to fairly size each bundle. Stuart Guterman, vice president of the Washington, D.C.-based Common-wealth Fund’s Program on Payment and System Reform, says one lesson from the capitation scheme of the ’90s is that an overemphasis on cost savings can lead to payments that are frequently insufficient to cover the costs of appropriate care.
“So there’s got to be more collaboration on what an appropriate amount is, and that’s a very important feature,” Guterman says. “Clearly, if you don’t pay enough, it doesn’t bode well for the success of any kind of payment approach. If you pay too much, it means you’re wasting money.”
The size and complexity of healthcare networks will influence how those bundle-related payments are negotiated. And in this case, several analysts say bigger isn’t necessarily better. “My own view is that it’s easier for a handful of hospitalists and a few community doctors in the hospital to come to an agreement on how they’re going to work within a bundle,” says Robert Berenson, MD, a senior fellow in the Urban Institute’s Health Policy Center and vice chair of the Medicare Payment Advisory Commission (MedPAC).
“My experience is that in rural communities, there’s a greater alliance of interests between the doctors and the hospitals, whereas in big urban areas they’re often competing with each other. So I don’t see that as the problem, frankly. I think this is probably better designed for smaller places where there’s already reasonably good relationships.”
L. Scott Sussman, MD, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, Vt., agrees that bundling likely wouldn’t negatively affect the day-to-day operations of the 25-bed critical-access hospital. Almost all admitted patients have PCPs in the affiliated Mt. Ascutney Physicians Practice, aiding communication during hospitalizations and care transitions. Dr. Sussman thinks bundling fits well with the mission of hospitalists to provide quality care and help smooth their patients’ transition back to community providers. “From the reading that I’ve done on bundling, it does seem to me that if implemented properly, it really could achieve cost savings while maintaining quality care,” he says.
Nevertheless, he has plenty of questions and concerns. Bundling would be more complicated, he concedes, if most admissions were referred from private-practice physicians in the community. And because Mt. Ascutney is a critical-access hospital, patients who develop complications or require a higher level of care are transferred to a tertiary-care facility—in this case, a 22-mile drive over the state line to Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “How would the payment be divided up at that point?” he asks.
To make bundling work, healthcare leaders will clearly need to blaze a trail through uncharted territory.
But if the goal is getting more from the trillions spent annually on healthcare, advocates like Guterman say it provides an important step toward a better-functioning system.
Among hospitalists, at least some observers are betting that bundling will ultimately find its way. “I think bundled payments are here to stay,” Dr. Aguirre says. “I think our goal now is to see how we can modify it or create it so it can have the best impact for us and we can have the best impact for it.” TH
Bryn Nelson is a freelance medical writer based in Seattle.
Members should “pony up” and run a 21st-century medical society
It was a propitious step to hear from Jeff Weise, MD, SFHM, current president of SHM, speaking in favor of increased transparency for our organization (see “To Err is Human,” October 2010, p. 42).
Encouragingly, when SHM has misstepped, we have corrected our transgressions. We have adopted rigorous conflict-of-interest policies, and we now disclose affiliations rapidly as a consequence—both for our board and for ranking members.
However, I do not believe, as Jeff states, we are the leaders in this domain. SHM still accepts large sums of money from industry, the exact amounts of which remain undisclosed on our website. Additionally, we underwrite our national meetings with corporate contributions, while other organizations have moved forward and shunned this process.1 Corporate sponsorship via branded logos are prominent on our website.
Granted, we are far from alone in this endeavor. Nevertheless, even with full disclosure, the appearance of purity is far from assured, as an outstanding essay commenting on AAFP’s acceptance of monies from Coca-Cola conveys.2
Calls to reform professional medical society practices are increasing, and the new healthcare legislation will begin to mandate recording, and then reporting, of physician-industry affiliations.3
Whether our organization will continue to “lead” on this front is unknown, and a question we must ask is, “Are our members prepared to pay full freight and pony up the costs of running our society in lieu of outside dollars?” I hope at some point the answer is “Yes.”
I for one would welcome full SHM disclosure, front and center, at our next national meeting. Similar to consumer-directed healthcare plan (CDHP) uptake lagging in the presence of opaque transaction costs at hospitals, we cannot change unless as members we know exactly what percentage of our activity others remunerate.
The “others,” as you can guess, are not physicians.
Bradley Flansbaum, DO, MPH, SFHM,
director, hospitalist services,
Lenox Hill Hospital, New York
References
- The American Psychiatric Association phases out industry-supported symposia. American Psychiatric Association website. Available at: http://psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/APAPhasesOutISS.aspx. Accessed Sept. 21, 2010.
- Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-358.
- Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA. 2009;301(13):1367-1372.
It was a propitious step to hear from Jeff Weise, MD, SFHM, current president of SHM, speaking in favor of increased transparency for our organization (see “To Err is Human,” October 2010, p. 42).
Encouragingly, when SHM has misstepped, we have corrected our transgressions. We have adopted rigorous conflict-of-interest policies, and we now disclose affiliations rapidly as a consequence—both for our board and for ranking members.
However, I do not believe, as Jeff states, we are the leaders in this domain. SHM still accepts large sums of money from industry, the exact amounts of which remain undisclosed on our website. Additionally, we underwrite our national meetings with corporate contributions, while other organizations have moved forward and shunned this process.1 Corporate sponsorship via branded logos are prominent on our website.
Granted, we are far from alone in this endeavor. Nevertheless, even with full disclosure, the appearance of purity is far from assured, as an outstanding essay commenting on AAFP’s acceptance of monies from Coca-Cola conveys.2
Calls to reform professional medical society practices are increasing, and the new healthcare legislation will begin to mandate recording, and then reporting, of physician-industry affiliations.3
Whether our organization will continue to “lead” on this front is unknown, and a question we must ask is, “Are our members prepared to pay full freight and pony up the costs of running our society in lieu of outside dollars?” I hope at some point the answer is “Yes.”
I for one would welcome full SHM disclosure, front and center, at our next national meeting. Similar to consumer-directed healthcare plan (CDHP) uptake lagging in the presence of opaque transaction costs at hospitals, we cannot change unless as members we know exactly what percentage of our activity others remunerate.
The “others,” as you can guess, are not physicians.
Bradley Flansbaum, DO, MPH, SFHM,
director, hospitalist services,
Lenox Hill Hospital, New York
References
- The American Psychiatric Association phases out industry-supported symposia. American Psychiatric Association website. Available at: http://psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/APAPhasesOutISS.aspx. Accessed Sept. 21, 2010.
- Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-358.
- Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA. 2009;301(13):1367-1372.
It was a propitious step to hear from Jeff Weise, MD, SFHM, current president of SHM, speaking in favor of increased transparency for our organization (see “To Err is Human,” October 2010, p. 42).
Encouragingly, when SHM has misstepped, we have corrected our transgressions. We have adopted rigorous conflict-of-interest policies, and we now disclose affiliations rapidly as a consequence—both for our board and for ranking members.
However, I do not believe, as Jeff states, we are the leaders in this domain. SHM still accepts large sums of money from industry, the exact amounts of which remain undisclosed on our website. Additionally, we underwrite our national meetings with corporate contributions, while other organizations have moved forward and shunned this process.1 Corporate sponsorship via branded logos are prominent on our website.
Granted, we are far from alone in this endeavor. Nevertheless, even with full disclosure, the appearance of purity is far from assured, as an outstanding essay commenting on AAFP’s acceptance of monies from Coca-Cola conveys.2
Calls to reform professional medical society practices are increasing, and the new healthcare legislation will begin to mandate recording, and then reporting, of physician-industry affiliations.3
Whether our organization will continue to “lead” on this front is unknown, and a question we must ask is, “Are our members prepared to pay full freight and pony up the costs of running our society in lieu of outside dollars?” I hope at some point the answer is “Yes.”
I for one would welcome full SHM disclosure, front and center, at our next national meeting. Similar to consumer-directed healthcare plan (CDHP) uptake lagging in the presence of opaque transaction costs at hospitals, we cannot change unless as members we know exactly what percentage of our activity others remunerate.
The “others,” as you can guess, are not physicians.
Bradley Flansbaum, DO, MPH, SFHM,
director, hospitalist services,
Lenox Hill Hospital, New York
References
- The American Psychiatric Association phases out industry-supported symposia. American Psychiatric Association website. Available at: http://psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/APAPhasesOutISS.aspx. Accessed Sept. 21, 2010.
- Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-358.
- Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA. 2009;301(13):1367-1372.
Career Challenge
Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.
That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.
The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.
The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.
“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”
For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.
A Better Way to Communicate
The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.
“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”
One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.
Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.
A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.
The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.
The Originals
Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.
The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.
The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.
“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”
The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:
- Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
- Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
- Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
- Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
- Implement methods of effective change through leadership, shared vision, and managing the organizational culture.
Participants in the second SHM Leadership Academy course build on those skills and learn to:
- Drive culture change through specific leadership behaviors and actions;
- Use financial reports to drive decision-making in clinical and operational practices;
- Recruit and retain the best physicians for their group;
- Build exceptional physician satisfaction; and
- Engage in effective, professional negotiation activities using proven techniques. TH
Brendon Shank is a freelance writer based in Philadelphia.
Fellow in Hospital Medicine Spotlight
Joseph Charles, MD, FACP, FHM
Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.
Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.
Medical school: Aberdeen University, Aberdeen, Scotland
Internship and residency: The Royal Infirmary in Aberdeen
Chief residency: Maricopa Medical Center in Phoenix
Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England
Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.
His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.
FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.
—Sarah Gelotte
HM11 Right Around the Corner
Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.
HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.
In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.
New pre-courses in 2011 include:
- Advanced Interactive Critical Care;
- Portable Ultrasound for the Hospitalist;
- Perioperative Medicine for the Hospitalist; and
- Succeeding in Challenging Times: Advances in Hospital Practice Management.
The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.
Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.
Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.
That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.
The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.
The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.
“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”
For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.
A Better Way to Communicate
The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.
“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”
One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.
Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.
A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.
The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.
The Originals
Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.
The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.
The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.
“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”
The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:
- Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
- Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
- Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
- Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
- Implement methods of effective change through leadership, shared vision, and managing the organizational culture.
Participants in the second SHM Leadership Academy course build on those skills and learn to:
- Drive culture change through specific leadership behaviors and actions;
- Use financial reports to drive decision-making in clinical and operational practices;
- Recruit and retain the best physicians for their group;
- Build exceptional physician satisfaction; and
- Engage in effective, professional negotiation activities using proven techniques. TH
Brendon Shank is a freelance writer based in Philadelphia.
Fellow in Hospital Medicine Spotlight
Joseph Charles, MD, FACP, FHM
Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.
Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.
Medical school: Aberdeen University, Aberdeen, Scotland
Internship and residency: The Royal Infirmary in Aberdeen
Chief residency: Maricopa Medical Center in Phoenix
Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England
Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.
His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.
FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.
—Sarah Gelotte
HM11 Right Around the Corner
Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.
HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.
In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.
New pre-courses in 2011 include:
- Advanced Interactive Critical Care;
- Portable Ultrasound for the Hospitalist;
- Perioperative Medicine for the Hospitalist; and
- Succeeding in Challenging Times: Advances in Hospital Practice Management.
The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.
Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.
Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.
That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.
The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.
The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.
“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”
For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.
A Better Way to Communicate
The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.
“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”
One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.
Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.
A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.
The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.
The Originals
Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.
The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.
The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.
“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”
The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:
- Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
- Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
- Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
- Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
- Implement methods of effective change through leadership, shared vision, and managing the organizational culture.
Participants in the second SHM Leadership Academy course build on those skills and learn to:
- Drive culture change through specific leadership behaviors and actions;
- Use financial reports to drive decision-making in clinical and operational practices;
- Recruit and retain the best physicians for their group;
- Build exceptional physician satisfaction; and
- Engage in effective, professional negotiation activities using proven techniques. TH
Brendon Shank is a freelance writer based in Philadelphia.
Fellow in Hospital Medicine Spotlight
Joseph Charles, MD, FACP, FHM
Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.
Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.
Medical school: Aberdeen University, Aberdeen, Scotland
Internship and residency: The Royal Infirmary in Aberdeen
Chief residency: Maricopa Medical Center in Phoenix
Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England
Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.
His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.
FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.
—Sarah Gelotte
HM11 Right Around the Corner
Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.
HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.
In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.
New pre-courses in 2011 include:
- Advanced Interactive Critical Care;
- Portable Ultrasound for the Hospitalist;
- Perioperative Medicine for the Hospitalist; and
- Succeeding in Challenging Times: Advances in Hospital Practice Management.
The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.
Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.
In the Literature: HM-Related Research You Need to Know
In This Edition
Literature at a Glance
A guide to this month’s studies
- Risk of infection with arterial and central venous catheters
- Rifaximin and prevention of hepatic encephalopathy
- Tracheotomy to prevent ventilator-associated pneumonia
- Coagulopathy and risk of VTE in patients with cirrhosis
- Use of age-adjusted D-dimer for PE diagnosis
- Continuation of anti-hypertensive medications after stroke
- Number of lumen cultures and detection of CRBSIs
- Timing of anticoagulation and outcomes in PE
Arterial and Central Venous Catheters Have Similar Rates of Colonization and Blood Stream Infections
Clinical question: Are arterial catheters (ACs) safer than central venous catheters (CVCs) in terms of colonization and catheter-related infections?
Background: Unlike CVCs, only a few studies have addressed blood-stream infections (BSI) related to AC usage, probably due to the traditional perception that ACs pose a lesser risk of colonization and BSI than CVC.
Study design: Randomized, controlled trial.
Setting: Three university hospitals and two general hospitals in France.
Synopsis: The study included 3,532 catheters (1,915 CVC and 1,617 AC) with 27,541 catheter-days from seven ICU settings. The same standard procedures were followed for catheter insertion and site dressing change at the various centers. Catheters were removed when they no longer were needed or when catheter-related infection (CRI) was suspected.
Colonization and CRI rates were similar in both arterial and venous catheters: 7.9% vs. 9.6% and 0.68% vs. 0.94%, respectively. The daily risk of colonization over time was stable for CVC, but appeared to increase for AC.
One important limitation to this study is that many patients had both arterial and venous catheters, leading to difficulty attributing infection to either one. Hospitalists caring for ICU patients should weigh the risks and benefits of prolonged use of AC due to similar rates of colonization and CRI as CVC.
Bottom line: Arterial and central venous catheters are equally prone to colonization and cause similar rates of CRI, but AC daily risk tends to increase with time; thus, AC should receive the same precautions as CVC.
Citation: Lucet JC, Bouadma L, Zahar JR, et. al. Infectious risk associated with arterial catheters compared with central venous catheters. Crit Care Med. 2010;38(4):1030-1005.
Rifaximin Prevents Recurrence of Hepatic Encephalopathy Episodes and Reduces Associated Risk for Hospitalization
Clinical question: What is the efficacy of rifaximin for the prevention of hepatic encephalopathy?
Background: Hepatic encephalopathy is a chronic, debilitating complication of liver cirrhosis. The efficacy of treatment of acute episodes with rifaximin is well documented in the literature; however, prevention of such episodes using rifaximin is poorly studied.
Study design: Randomized, double-blinded, placebo-controlled trial.
Setting: Seventy centers in the U.S., Canada, and Russia.
Synopsis: A total of 299 chronic liver disease patients, in remission from recurrent hepatic encephalopathy, randomly were assigned to receive either oral rifaximin (140 patients) or placebo (159 patients) for six months.
When compared to placebo, rifaximin reduced the risk of breakthrough episodes of hepatic encephalopathy over a six-month treatment period (22.1% vs 45.9%, HR 0.42; 95% confidence interval, 0.28-0.64, P<0.001), as well as risk of hospitalization involving hepatic encephalopathy (13.6% vs 22.6%, HR 0.50; 95% CI, 0.29-0.87, P=0.01).
The incidence of adverse effects was similar in both groups. More than 90% of patients received concomitant lactulose therapy.
Bottom line: Rifaximin treatment delays the first breakthrough episode of hepatic encephalopathy during a six-month period; moreover, it significantly reduces the associated risk for hospitalization.
Citation: Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071-1081.
Early Tracheotomy Does Not Decrease the Incidence of Ventilator-Associated Pneumonia in ICU Patients
Clinical question: Does early tracheotomy decrease the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated adult ICU patients without existing lung infection?
Background: There is considerable variation in timing and incidence of tracheotomy across ICUs. Observational studies have reported that tracheotomy performed earlier might be associated with quicker weaning from mechanical ventilation; however, randomized, controlled trials have failed to confirm this finding.
Study design: Multicenter randomized controlled trial.
Setting: Adult ICU in Italy.
Synopsis: Between 2004 and 2008, 600 mechanically ventilated patients without lung infection were enrolled from 12 adult ICUs in Italy. Of these patients, 419 were randomized to early tracheotomy performed six to eight days after intubation (N=209) or to late tracheotomy performed 13-15 days after intubation (N=210).
VAP was diagnosed in 14% of patients in the early tracheotomy group, compared with 21% in the late tracheotomy group (P=0.07). Although the number of ventilator-free and ICU-free days was higher in the early tracheotomy group, long-term outcomes did not differ between the two groups.
Only 69% of patients in the early tracheotomy group and 57% of patients in the late tracheotomy group received tracheotomy, but all the patients were included in the final analysis due to the intention-to-treat design of the study, which might have diluted the effect of the intervention. In addition, the smaller sample size may have prevented the study from reaching statistical significance.
Bottom line: Early tracheotomy does not significantly decrease the incidence of VAP as compared to late tracheotomy.
Citation: Terragni PP, Antonelli M, Fumagalli R, et al. Early vs. late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients. JAMA. 2010;303(15): 1483-1489.
Coagulopathy in Cirrhotic Patients Is Not Protective against VTE
Clinical question: Does the degree of INR elevation affect the incidence of VTE in hospitalized patients with cirrhosis?
Background: Chronic liver disease (CLD) and subsequent development of cirrhosis renders patients coagulopathic. Historically, this has provided a sense of security to clinicians that these patients inherently possess a decreased VTE risk.
Study design: Retrospective cohort study.
Setting: University of Missouri Medical Center in Columbia.
Synopsis: Chart review of patients admitted with CLD and cirrhosis from Jan. 1, 2000, and Jan. 31, 2007, demonstrated an incidence rate of VTE of 6.3%, which is much higher than previous reports.
Most patients with CLD received no thrombosis prophylaxis; notably, there was no difference in VTE incidence between subgroups who received prophylaxis and those who did not. Five percent of VTE cases occurred in patients with an INR exceeding 1.6, with Child-Pugh class C patients having the highest thromboembolism incidence.
This retrospective chart review was limited by information and reporting bias and the inability to control confounding variables. Less than half of the patients were screened for VTE, which means that the true incidence of thrombus could actually be higher. Further studies are needed to provide proper risk assessment.
Bottom line: Patients with CLD and cirrhosis are at risk for VTE, even in the setting of coagulopathy, and might require VTE prophylaxis.
Citation: Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;137(5):1145-1149.
Pulmonary Embolism Can Be Safely Excluded Using Age-Adjusted D-dimer Cut-off Value
Clinical question: Does the new age-adjusted D-dimer cutoff value in older patients safely exclude pulmonary embolism (PE)?
Background: D-dimer is a useful blood test to exclude PE; however, D-dimer concentration increases with age, and hence the current cutoff of 500µg/l used in excluding a PE becomes less specific in older patients.
Study design: Retrospective multicenter cohort study.
Setting: General and teaching hospitals in Belgium, Switzerland, France, and Netherlands.
Synopsis: The study included 5,132 consecutive patients with clinically suspected PE. Patients were distributed into a derivation set (N=1,331) and two independent validation sets (N1=2,151 and N2=1,643). For patients older than 50, the use of the new age-adjusted D-dimer cutoff (patient age multiplied by 10µg/l) resulted in a combined 11% increase in the number of patients with negative results. This increase was more prominent in patients aged older than 70 (13% to 16%).
The new age-adjusted D-dimer cutoff point failed to detect PE in 0.2% of cases in the derivation set and in 0.6% and 0.3% of cases in the two validation sets, respectively. However, despite external validation, prospective studies are needed before implementing such criteria into clinical practice.
Bottom line: The age-adjusted D-dimer combined with clinical probability greatly increases the proportion of older patients in whom PE can be safely excluded.
Citation: Douma RA, Le Gal G, Söhne M, et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ. 2010;340:c1475.
Antihypertensive Drugs After Stroke Does Not Impact Cardiovascular Event Rate or Mortality at Six Months
Clinical question: Should antihypertensive medications be continued during the immediate post-stroke period in patients who previously were on such therapy?
Background: More than 50% of patients suffering from acute stroke are on antihypertensive therapy prior to admission. However, efficacy of such therapy in reducing cardiovascular event rates and mortality in the immediate post-stroke period is not well studied.
Study design: Prospective, randomized, open-blinded-endpoint trial.
Setting: Forty-nine UK National Institute for Health Research Stroke Centers.
Synopsis: From January 2003 and March 2009, 763 patients with pre-existing hypertension and diagnosis of mild to moderate acute stroke were recruited and assigned to continue or stop antihypertension drugs. The time limit for inclusion into the study was within 48 hours of the stroke and the endpoint was death or dependency (modified Rankin Scale >3) at the end of two weeks.
There was a statistically significant difference in the two groups at two weeks in both systolic and diastolic pressures, 13 mmHg and 8mmHg, respectively (P<0.0001). Seventy-two of 379 patients in the continuation group and 82 of 384 patients in the stop group reached the primary endpoint (P=0.3). The latter point is a major limitation to this trial, since it was underpowered because of early termination to detect differences in outcomes.
Bottom line: Antihypertensive therapy during the immediate post-stroke period did not reduce two-week death or dependency, cardiovascular event rate, or mortality at six months.
Citation: Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the continue or stop post-stroke antihypertensives collaborative study (COSSACS): a prospective, randomized, open, blinded-endpoint trial. Lancet Neurol. 2010;9:767-775.
All Lumens from Multi-Lumen Catheters Should Be Cultured to Diagnose Catheter-Related Bloodstream Infections
Clinical question: Do all lumens from multi-lumen catheters need to be cultured to best diagnose catheter-related bloodstream infections (CRBSIs)?
Background: The recent Infectious Diseases Society of America’s “Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections” has not conclusively established the number of lumens to culture from multi-lumen catheters when attempting to diagnose CRBSIs.
Study design: Retrospective cohort study.
Setting: Large teaching institution in Spain.
Synopsis: From January 2003 until May 2009, 154 patients, mostly men, with a mean age of 58.1 years, were recruited to participate in the study. Of these, 171 episodes of proven CRBSIs were detected in 154 subjects. Of the 171 tested catheters (112 double lumen and 59 triple lumen), testing only one lumen from double catheters would have led to 27.2% of missed cases for CRBSIs. Additionally, testing only two or one lumen from triple lumen catheters would have led to 15.8% and 37.3% of missed cases for CRBSIs, respectively.
The study was limited by being conducted at a single test site and the need to withdraw catheters to perform endoluminal brushing and semi-quantitative techniques. Though diagnostic yield might significantly improve by culturing all multi-lumen sites, hospitalists should consider the time and cost expenditure for testing from more than one lumen.
Bottom line: Culturing all lumens from multi-lumen catheters could greatly increase diagnostic yield in CRBSIs.
Citation: Guembe M, Rodríguez-Créixems M, Sánchez-Carrillo C, Pérez-Parra A, Martín-Rabadán P, Bouza E. How many lumens should be cultured in the conservative diagnosis of catheter-related bloodstream infections? CID. 2010;50(12):1575-1579.
Early Anticoagulation Improves Survival after Acute PE
Clinical question: Does the timing of initial heparinization reduce mortality in patients with acute symptomatic PE?
Background: Acute PE is rapidly fatal if not diagnosed and treated. Studies have shown that intravenous heparin improves overall survival for patients with PE, and therapeutic anticoagulation reduces rates of recurrent VTE. However, studies investigating the relation between time to achieve therapeutic anticoagulation and mortality or PE recurrence are limited.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: From June 2002 and September 2005, 400 patients were identified with PE using retrospective data from Mayo Clinic’s electronic medical records. Patients who received heparin in the ED had lower in-hospital mortality (OR 0.20, 95% CI, 0.06-0.69) and 30-day mortality (OR 0.25, 95% CI, 0.12-0.55) compared with patients who received heparin after admission. Similarly, patients who achieved a therapeutic aPTT within 24 hours also had lower 30-day mortality (OR 0.34, 95% CI, 0.14-0.84). Patients with COPD and malignancies had higher in-hospital and 30-day mortality, respectively.
Bottom line: It is difficult to draw a causal relationship from a retrospective review, but hospitalists should start immediate anticoagulation therapy when a PE is suspected.
Citation: Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6): 1382-1390. TH
PEDIATRIC HM LITERATURE
Ibuprofen Use Associated with Complicated Pneumonia
Clinical question: What baseline characteristics are associated with suppurative complications in children hospitalized with community-acquired pneumonia?
Background: The prevalence of suppurative complications of community-acquired pneumonia (CAP) appears to be on the rise. Reasons for this increase remain unclear, although etiologic organism, older age, prior antibiotic, and nonsteroidal anti-inflammatory drug use have been implicated in a single prior retrospective study.
Study design: Retrospective cohort study.
Setting: Two hospitals in France.
Synopsis: Two physicians reviewed 1,184 charts based on ICD-10 discharge codes for pneumonia from 1995 to 2003. Children younger than 28 days and older than 15 years were excluded. Additionally, children with underlying or cardiorespiratory pathology were excluded. After applying predefined clinical criteria for pneumonia and suppurative complications, 677 children with CAP were compared to 90 with suppurative complications of pneumonia.
The incidence of suppurative complications increased to 13 per 100,000 from 0.5 per 100,000 over the time period. A minority of patients had etiologic microbes isolated, primarily Streptococcus pneumoniae, in both groups. Complicated pneumonia was more frequently seen in older children, and in children with prior antibiotic and anti-inflammatory medication use. After multivariable analysis, only ibuprofen use remained with an increased odds ratio (2.57, 95% confidence interval, 1.51-4.35) of complicated pneumonia.
The clear drawback of this study is an inability to draw a causal connection between ibuprofen use and the development of suppurative complications of pneumonia. The retrospective nature of the analysis further limits hypothesis generation. Nevertheless, it is notable that the results corroborate findings from a prior study in the U.S., in which ibuprofen was found to significantly increase the likelihood of parapneumonic empyema.
Bottom line: Ibuprofen use is associated with the development of suppurative complications of pneumonia.
Citation: François P, Desrumaux A, Cans C, Pin I, Pavese P, Labarère J. Prevalence and risk factors of suppurative complications in children with pneumonia. Acta Paediatr. 2010;99(6):861-866.
In This Edition
Literature at a Glance
A guide to this month’s studies
- Risk of infection with arterial and central venous catheters
- Rifaximin and prevention of hepatic encephalopathy
- Tracheotomy to prevent ventilator-associated pneumonia
- Coagulopathy and risk of VTE in patients with cirrhosis
- Use of age-adjusted D-dimer for PE diagnosis
- Continuation of anti-hypertensive medications after stroke
- Number of lumen cultures and detection of CRBSIs
- Timing of anticoagulation and outcomes in PE
Arterial and Central Venous Catheters Have Similar Rates of Colonization and Blood Stream Infections
Clinical question: Are arterial catheters (ACs) safer than central venous catheters (CVCs) in terms of colonization and catheter-related infections?
Background: Unlike CVCs, only a few studies have addressed blood-stream infections (BSI) related to AC usage, probably due to the traditional perception that ACs pose a lesser risk of colonization and BSI than CVC.
Study design: Randomized, controlled trial.
Setting: Three university hospitals and two general hospitals in France.
Synopsis: The study included 3,532 catheters (1,915 CVC and 1,617 AC) with 27,541 catheter-days from seven ICU settings. The same standard procedures were followed for catheter insertion and site dressing change at the various centers. Catheters were removed when they no longer were needed or when catheter-related infection (CRI) was suspected.
Colonization and CRI rates were similar in both arterial and venous catheters: 7.9% vs. 9.6% and 0.68% vs. 0.94%, respectively. The daily risk of colonization over time was stable for CVC, but appeared to increase for AC.
One important limitation to this study is that many patients had both arterial and venous catheters, leading to difficulty attributing infection to either one. Hospitalists caring for ICU patients should weigh the risks and benefits of prolonged use of AC due to similar rates of colonization and CRI as CVC.
Bottom line: Arterial and central venous catheters are equally prone to colonization and cause similar rates of CRI, but AC daily risk tends to increase with time; thus, AC should receive the same precautions as CVC.
Citation: Lucet JC, Bouadma L, Zahar JR, et. al. Infectious risk associated with arterial catheters compared with central venous catheters. Crit Care Med. 2010;38(4):1030-1005.
Rifaximin Prevents Recurrence of Hepatic Encephalopathy Episodes and Reduces Associated Risk for Hospitalization
Clinical question: What is the efficacy of rifaximin for the prevention of hepatic encephalopathy?
Background: Hepatic encephalopathy is a chronic, debilitating complication of liver cirrhosis. The efficacy of treatment of acute episodes with rifaximin is well documented in the literature; however, prevention of such episodes using rifaximin is poorly studied.
Study design: Randomized, double-blinded, placebo-controlled trial.
Setting: Seventy centers in the U.S., Canada, and Russia.
Synopsis: A total of 299 chronic liver disease patients, in remission from recurrent hepatic encephalopathy, randomly were assigned to receive either oral rifaximin (140 patients) or placebo (159 patients) for six months.
When compared to placebo, rifaximin reduced the risk of breakthrough episodes of hepatic encephalopathy over a six-month treatment period (22.1% vs 45.9%, HR 0.42; 95% confidence interval, 0.28-0.64, P<0.001), as well as risk of hospitalization involving hepatic encephalopathy (13.6% vs 22.6%, HR 0.50; 95% CI, 0.29-0.87, P=0.01).
The incidence of adverse effects was similar in both groups. More than 90% of patients received concomitant lactulose therapy.
Bottom line: Rifaximin treatment delays the first breakthrough episode of hepatic encephalopathy during a six-month period; moreover, it significantly reduces the associated risk for hospitalization.
Citation: Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071-1081.
Early Tracheotomy Does Not Decrease the Incidence of Ventilator-Associated Pneumonia in ICU Patients
Clinical question: Does early tracheotomy decrease the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated adult ICU patients without existing lung infection?
Background: There is considerable variation in timing and incidence of tracheotomy across ICUs. Observational studies have reported that tracheotomy performed earlier might be associated with quicker weaning from mechanical ventilation; however, randomized, controlled trials have failed to confirm this finding.
Study design: Multicenter randomized controlled trial.
Setting: Adult ICU in Italy.
Synopsis: Between 2004 and 2008, 600 mechanically ventilated patients without lung infection were enrolled from 12 adult ICUs in Italy. Of these patients, 419 were randomized to early tracheotomy performed six to eight days after intubation (N=209) or to late tracheotomy performed 13-15 days after intubation (N=210).
VAP was diagnosed in 14% of patients in the early tracheotomy group, compared with 21% in the late tracheotomy group (P=0.07). Although the number of ventilator-free and ICU-free days was higher in the early tracheotomy group, long-term outcomes did not differ between the two groups.
Only 69% of patients in the early tracheotomy group and 57% of patients in the late tracheotomy group received tracheotomy, but all the patients were included in the final analysis due to the intention-to-treat design of the study, which might have diluted the effect of the intervention. In addition, the smaller sample size may have prevented the study from reaching statistical significance.
Bottom line: Early tracheotomy does not significantly decrease the incidence of VAP as compared to late tracheotomy.
Citation: Terragni PP, Antonelli M, Fumagalli R, et al. Early vs. late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients. JAMA. 2010;303(15): 1483-1489.
Coagulopathy in Cirrhotic Patients Is Not Protective against VTE
Clinical question: Does the degree of INR elevation affect the incidence of VTE in hospitalized patients with cirrhosis?
Background: Chronic liver disease (CLD) and subsequent development of cirrhosis renders patients coagulopathic. Historically, this has provided a sense of security to clinicians that these patients inherently possess a decreased VTE risk.
Study design: Retrospective cohort study.
Setting: University of Missouri Medical Center in Columbia.
Synopsis: Chart review of patients admitted with CLD and cirrhosis from Jan. 1, 2000, and Jan. 31, 2007, demonstrated an incidence rate of VTE of 6.3%, which is much higher than previous reports.
Most patients with CLD received no thrombosis prophylaxis; notably, there was no difference in VTE incidence between subgroups who received prophylaxis and those who did not. Five percent of VTE cases occurred in patients with an INR exceeding 1.6, with Child-Pugh class C patients having the highest thromboembolism incidence.
This retrospective chart review was limited by information and reporting bias and the inability to control confounding variables. Less than half of the patients were screened for VTE, which means that the true incidence of thrombus could actually be higher. Further studies are needed to provide proper risk assessment.
Bottom line: Patients with CLD and cirrhosis are at risk for VTE, even in the setting of coagulopathy, and might require VTE prophylaxis.
Citation: Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;137(5):1145-1149.
Pulmonary Embolism Can Be Safely Excluded Using Age-Adjusted D-dimer Cut-off Value
Clinical question: Does the new age-adjusted D-dimer cutoff value in older patients safely exclude pulmonary embolism (PE)?
Background: D-dimer is a useful blood test to exclude PE; however, D-dimer concentration increases with age, and hence the current cutoff of 500µg/l used in excluding a PE becomes less specific in older patients.
Study design: Retrospective multicenter cohort study.
Setting: General and teaching hospitals in Belgium, Switzerland, France, and Netherlands.
Synopsis: The study included 5,132 consecutive patients with clinically suspected PE. Patients were distributed into a derivation set (N=1,331) and two independent validation sets (N1=2,151 and N2=1,643). For patients older than 50, the use of the new age-adjusted D-dimer cutoff (patient age multiplied by 10µg/l) resulted in a combined 11% increase in the number of patients with negative results. This increase was more prominent in patients aged older than 70 (13% to 16%).
The new age-adjusted D-dimer cutoff point failed to detect PE in 0.2% of cases in the derivation set and in 0.6% and 0.3% of cases in the two validation sets, respectively. However, despite external validation, prospective studies are needed before implementing such criteria into clinical practice.
Bottom line: The age-adjusted D-dimer combined with clinical probability greatly increases the proportion of older patients in whom PE can be safely excluded.
Citation: Douma RA, Le Gal G, Söhne M, et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ. 2010;340:c1475.
Antihypertensive Drugs After Stroke Does Not Impact Cardiovascular Event Rate or Mortality at Six Months
Clinical question: Should antihypertensive medications be continued during the immediate post-stroke period in patients who previously were on such therapy?
Background: More than 50% of patients suffering from acute stroke are on antihypertensive therapy prior to admission. However, efficacy of such therapy in reducing cardiovascular event rates and mortality in the immediate post-stroke period is not well studied.
Study design: Prospective, randomized, open-blinded-endpoint trial.
Setting: Forty-nine UK National Institute for Health Research Stroke Centers.
Synopsis: From January 2003 and March 2009, 763 patients with pre-existing hypertension and diagnosis of mild to moderate acute stroke were recruited and assigned to continue or stop antihypertension drugs. The time limit for inclusion into the study was within 48 hours of the stroke and the endpoint was death or dependency (modified Rankin Scale >3) at the end of two weeks.
There was a statistically significant difference in the two groups at two weeks in both systolic and diastolic pressures, 13 mmHg and 8mmHg, respectively (P<0.0001). Seventy-two of 379 patients in the continuation group and 82 of 384 patients in the stop group reached the primary endpoint (P=0.3). The latter point is a major limitation to this trial, since it was underpowered because of early termination to detect differences in outcomes.
Bottom line: Antihypertensive therapy during the immediate post-stroke period did not reduce two-week death or dependency, cardiovascular event rate, or mortality at six months.
Citation: Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the continue or stop post-stroke antihypertensives collaborative study (COSSACS): a prospective, randomized, open, blinded-endpoint trial. Lancet Neurol. 2010;9:767-775.
All Lumens from Multi-Lumen Catheters Should Be Cultured to Diagnose Catheter-Related Bloodstream Infections
Clinical question: Do all lumens from multi-lumen catheters need to be cultured to best diagnose catheter-related bloodstream infections (CRBSIs)?
Background: The recent Infectious Diseases Society of America’s “Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections” has not conclusively established the number of lumens to culture from multi-lumen catheters when attempting to diagnose CRBSIs.
Study design: Retrospective cohort study.
Setting: Large teaching institution in Spain.
Synopsis: From January 2003 until May 2009, 154 patients, mostly men, with a mean age of 58.1 years, were recruited to participate in the study. Of these, 171 episodes of proven CRBSIs were detected in 154 subjects. Of the 171 tested catheters (112 double lumen and 59 triple lumen), testing only one lumen from double catheters would have led to 27.2% of missed cases for CRBSIs. Additionally, testing only two or one lumen from triple lumen catheters would have led to 15.8% and 37.3% of missed cases for CRBSIs, respectively.
The study was limited by being conducted at a single test site and the need to withdraw catheters to perform endoluminal brushing and semi-quantitative techniques. Though diagnostic yield might significantly improve by culturing all multi-lumen sites, hospitalists should consider the time and cost expenditure for testing from more than one lumen.
Bottom line: Culturing all lumens from multi-lumen catheters could greatly increase diagnostic yield in CRBSIs.
Citation: Guembe M, Rodríguez-Créixems M, Sánchez-Carrillo C, Pérez-Parra A, Martín-Rabadán P, Bouza E. How many lumens should be cultured in the conservative diagnosis of catheter-related bloodstream infections? CID. 2010;50(12):1575-1579.
Early Anticoagulation Improves Survival after Acute PE
Clinical question: Does the timing of initial heparinization reduce mortality in patients with acute symptomatic PE?
Background: Acute PE is rapidly fatal if not diagnosed and treated. Studies have shown that intravenous heparin improves overall survival for patients with PE, and therapeutic anticoagulation reduces rates of recurrent VTE. However, studies investigating the relation between time to achieve therapeutic anticoagulation and mortality or PE recurrence are limited.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: From June 2002 and September 2005, 400 patients were identified with PE using retrospective data from Mayo Clinic’s electronic medical records. Patients who received heparin in the ED had lower in-hospital mortality (OR 0.20, 95% CI, 0.06-0.69) and 30-day mortality (OR 0.25, 95% CI, 0.12-0.55) compared with patients who received heparin after admission. Similarly, patients who achieved a therapeutic aPTT within 24 hours also had lower 30-day mortality (OR 0.34, 95% CI, 0.14-0.84). Patients with COPD and malignancies had higher in-hospital and 30-day mortality, respectively.
Bottom line: It is difficult to draw a causal relationship from a retrospective review, but hospitalists should start immediate anticoagulation therapy when a PE is suspected.
Citation: Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6): 1382-1390. TH
PEDIATRIC HM LITERATURE
Ibuprofen Use Associated with Complicated Pneumonia
Clinical question: What baseline characteristics are associated with suppurative complications in children hospitalized with community-acquired pneumonia?
Background: The prevalence of suppurative complications of community-acquired pneumonia (CAP) appears to be on the rise. Reasons for this increase remain unclear, although etiologic organism, older age, prior antibiotic, and nonsteroidal anti-inflammatory drug use have been implicated in a single prior retrospective study.
Study design: Retrospective cohort study.
Setting: Two hospitals in France.
Synopsis: Two physicians reviewed 1,184 charts based on ICD-10 discharge codes for pneumonia from 1995 to 2003. Children younger than 28 days and older than 15 years were excluded. Additionally, children with underlying or cardiorespiratory pathology were excluded. After applying predefined clinical criteria for pneumonia and suppurative complications, 677 children with CAP were compared to 90 with suppurative complications of pneumonia.
The incidence of suppurative complications increased to 13 per 100,000 from 0.5 per 100,000 over the time period. A minority of patients had etiologic microbes isolated, primarily Streptococcus pneumoniae, in both groups. Complicated pneumonia was more frequently seen in older children, and in children with prior antibiotic and anti-inflammatory medication use. After multivariable analysis, only ibuprofen use remained with an increased odds ratio (2.57, 95% confidence interval, 1.51-4.35) of complicated pneumonia.
The clear drawback of this study is an inability to draw a causal connection between ibuprofen use and the development of suppurative complications of pneumonia. The retrospective nature of the analysis further limits hypothesis generation. Nevertheless, it is notable that the results corroborate findings from a prior study in the U.S., in which ibuprofen was found to significantly increase the likelihood of parapneumonic empyema.
Bottom line: Ibuprofen use is associated with the development of suppurative complications of pneumonia.
Citation: François P, Desrumaux A, Cans C, Pin I, Pavese P, Labarère J. Prevalence and risk factors of suppurative complications in children with pneumonia. Acta Paediatr. 2010;99(6):861-866.
In This Edition
Literature at a Glance
A guide to this month’s studies
- Risk of infection with arterial and central venous catheters
- Rifaximin and prevention of hepatic encephalopathy
- Tracheotomy to prevent ventilator-associated pneumonia
- Coagulopathy and risk of VTE in patients with cirrhosis
- Use of age-adjusted D-dimer for PE diagnosis
- Continuation of anti-hypertensive medications after stroke
- Number of lumen cultures and detection of CRBSIs
- Timing of anticoagulation and outcomes in PE
Arterial and Central Venous Catheters Have Similar Rates of Colonization and Blood Stream Infections
Clinical question: Are arterial catheters (ACs) safer than central venous catheters (CVCs) in terms of colonization and catheter-related infections?
Background: Unlike CVCs, only a few studies have addressed blood-stream infections (BSI) related to AC usage, probably due to the traditional perception that ACs pose a lesser risk of colonization and BSI than CVC.
Study design: Randomized, controlled trial.
Setting: Three university hospitals and two general hospitals in France.
Synopsis: The study included 3,532 catheters (1,915 CVC and 1,617 AC) with 27,541 catheter-days from seven ICU settings. The same standard procedures were followed for catheter insertion and site dressing change at the various centers. Catheters were removed when they no longer were needed or when catheter-related infection (CRI) was suspected.
Colonization and CRI rates were similar in both arterial and venous catheters: 7.9% vs. 9.6% and 0.68% vs. 0.94%, respectively. The daily risk of colonization over time was stable for CVC, but appeared to increase for AC.
One important limitation to this study is that many patients had both arterial and venous catheters, leading to difficulty attributing infection to either one. Hospitalists caring for ICU patients should weigh the risks and benefits of prolonged use of AC due to similar rates of colonization and CRI as CVC.
Bottom line: Arterial and central venous catheters are equally prone to colonization and cause similar rates of CRI, but AC daily risk tends to increase with time; thus, AC should receive the same precautions as CVC.
Citation: Lucet JC, Bouadma L, Zahar JR, et. al. Infectious risk associated with arterial catheters compared with central venous catheters. Crit Care Med. 2010;38(4):1030-1005.
Rifaximin Prevents Recurrence of Hepatic Encephalopathy Episodes and Reduces Associated Risk for Hospitalization
Clinical question: What is the efficacy of rifaximin for the prevention of hepatic encephalopathy?
Background: Hepatic encephalopathy is a chronic, debilitating complication of liver cirrhosis. The efficacy of treatment of acute episodes with rifaximin is well documented in the literature; however, prevention of such episodes using rifaximin is poorly studied.
Study design: Randomized, double-blinded, placebo-controlled trial.
Setting: Seventy centers in the U.S., Canada, and Russia.
Synopsis: A total of 299 chronic liver disease patients, in remission from recurrent hepatic encephalopathy, randomly were assigned to receive either oral rifaximin (140 patients) or placebo (159 patients) for six months.
When compared to placebo, rifaximin reduced the risk of breakthrough episodes of hepatic encephalopathy over a six-month treatment period (22.1% vs 45.9%, HR 0.42; 95% confidence interval, 0.28-0.64, P<0.001), as well as risk of hospitalization involving hepatic encephalopathy (13.6% vs 22.6%, HR 0.50; 95% CI, 0.29-0.87, P=0.01).
The incidence of adverse effects was similar in both groups. More than 90% of patients received concomitant lactulose therapy.
Bottom line: Rifaximin treatment delays the first breakthrough episode of hepatic encephalopathy during a six-month period; moreover, it significantly reduces the associated risk for hospitalization.
Citation: Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071-1081.
Early Tracheotomy Does Not Decrease the Incidence of Ventilator-Associated Pneumonia in ICU Patients
Clinical question: Does early tracheotomy decrease the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated adult ICU patients without existing lung infection?
Background: There is considerable variation in timing and incidence of tracheotomy across ICUs. Observational studies have reported that tracheotomy performed earlier might be associated with quicker weaning from mechanical ventilation; however, randomized, controlled trials have failed to confirm this finding.
Study design: Multicenter randomized controlled trial.
Setting: Adult ICU in Italy.
Synopsis: Between 2004 and 2008, 600 mechanically ventilated patients without lung infection were enrolled from 12 adult ICUs in Italy. Of these patients, 419 were randomized to early tracheotomy performed six to eight days after intubation (N=209) or to late tracheotomy performed 13-15 days after intubation (N=210).
VAP was diagnosed in 14% of patients in the early tracheotomy group, compared with 21% in the late tracheotomy group (P=0.07). Although the number of ventilator-free and ICU-free days was higher in the early tracheotomy group, long-term outcomes did not differ between the two groups.
Only 69% of patients in the early tracheotomy group and 57% of patients in the late tracheotomy group received tracheotomy, but all the patients were included in the final analysis due to the intention-to-treat design of the study, which might have diluted the effect of the intervention. In addition, the smaller sample size may have prevented the study from reaching statistical significance.
Bottom line: Early tracheotomy does not significantly decrease the incidence of VAP as compared to late tracheotomy.
Citation: Terragni PP, Antonelli M, Fumagalli R, et al. Early vs. late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients. JAMA. 2010;303(15): 1483-1489.
Coagulopathy in Cirrhotic Patients Is Not Protective against VTE
Clinical question: Does the degree of INR elevation affect the incidence of VTE in hospitalized patients with cirrhosis?
Background: Chronic liver disease (CLD) and subsequent development of cirrhosis renders patients coagulopathic. Historically, this has provided a sense of security to clinicians that these patients inherently possess a decreased VTE risk.
Study design: Retrospective cohort study.
Setting: University of Missouri Medical Center in Columbia.
Synopsis: Chart review of patients admitted with CLD and cirrhosis from Jan. 1, 2000, and Jan. 31, 2007, demonstrated an incidence rate of VTE of 6.3%, which is much higher than previous reports.
Most patients with CLD received no thrombosis prophylaxis; notably, there was no difference in VTE incidence between subgroups who received prophylaxis and those who did not. Five percent of VTE cases occurred in patients with an INR exceeding 1.6, with Child-Pugh class C patients having the highest thromboembolism incidence.
This retrospective chart review was limited by information and reporting bias and the inability to control confounding variables. Less than half of the patients were screened for VTE, which means that the true incidence of thrombus could actually be higher. Further studies are needed to provide proper risk assessment.
Bottom line: Patients with CLD and cirrhosis are at risk for VTE, even in the setting of coagulopathy, and might require VTE prophylaxis.
Citation: Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;137(5):1145-1149.
Pulmonary Embolism Can Be Safely Excluded Using Age-Adjusted D-dimer Cut-off Value
Clinical question: Does the new age-adjusted D-dimer cutoff value in older patients safely exclude pulmonary embolism (PE)?
Background: D-dimer is a useful blood test to exclude PE; however, D-dimer concentration increases with age, and hence the current cutoff of 500µg/l used in excluding a PE becomes less specific in older patients.
Study design: Retrospective multicenter cohort study.
Setting: General and teaching hospitals in Belgium, Switzerland, France, and Netherlands.
Synopsis: The study included 5,132 consecutive patients with clinically suspected PE. Patients were distributed into a derivation set (N=1,331) and two independent validation sets (N1=2,151 and N2=1,643). For patients older than 50, the use of the new age-adjusted D-dimer cutoff (patient age multiplied by 10µg/l) resulted in a combined 11% increase in the number of patients with negative results. This increase was more prominent in patients aged older than 70 (13% to 16%).
The new age-adjusted D-dimer cutoff point failed to detect PE in 0.2% of cases in the derivation set and in 0.6% and 0.3% of cases in the two validation sets, respectively. However, despite external validation, prospective studies are needed before implementing such criteria into clinical practice.
Bottom line: The age-adjusted D-dimer combined with clinical probability greatly increases the proportion of older patients in whom PE can be safely excluded.
Citation: Douma RA, Le Gal G, Söhne M, et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ. 2010;340:c1475.
Antihypertensive Drugs After Stroke Does Not Impact Cardiovascular Event Rate or Mortality at Six Months
Clinical question: Should antihypertensive medications be continued during the immediate post-stroke period in patients who previously were on such therapy?
Background: More than 50% of patients suffering from acute stroke are on antihypertensive therapy prior to admission. However, efficacy of such therapy in reducing cardiovascular event rates and mortality in the immediate post-stroke period is not well studied.
Study design: Prospective, randomized, open-blinded-endpoint trial.
Setting: Forty-nine UK National Institute for Health Research Stroke Centers.
Synopsis: From January 2003 and March 2009, 763 patients with pre-existing hypertension and diagnosis of mild to moderate acute stroke were recruited and assigned to continue or stop antihypertension drugs. The time limit for inclusion into the study was within 48 hours of the stroke and the endpoint was death or dependency (modified Rankin Scale >3) at the end of two weeks.
There was a statistically significant difference in the two groups at two weeks in both systolic and diastolic pressures, 13 mmHg and 8mmHg, respectively (P<0.0001). Seventy-two of 379 patients in the continuation group and 82 of 384 patients in the stop group reached the primary endpoint (P=0.3). The latter point is a major limitation to this trial, since it was underpowered because of early termination to detect differences in outcomes.
Bottom line: Antihypertensive therapy during the immediate post-stroke period did not reduce two-week death or dependency, cardiovascular event rate, or mortality at six months.
Citation: Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the continue or stop post-stroke antihypertensives collaborative study (COSSACS): a prospective, randomized, open, blinded-endpoint trial. Lancet Neurol. 2010;9:767-775.
All Lumens from Multi-Lumen Catheters Should Be Cultured to Diagnose Catheter-Related Bloodstream Infections
Clinical question: Do all lumens from multi-lumen catheters need to be cultured to best diagnose catheter-related bloodstream infections (CRBSIs)?
Background: The recent Infectious Diseases Society of America’s “Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections” has not conclusively established the number of lumens to culture from multi-lumen catheters when attempting to diagnose CRBSIs.
Study design: Retrospective cohort study.
Setting: Large teaching institution in Spain.
Synopsis: From January 2003 until May 2009, 154 patients, mostly men, with a mean age of 58.1 years, were recruited to participate in the study. Of these, 171 episodes of proven CRBSIs were detected in 154 subjects. Of the 171 tested catheters (112 double lumen and 59 triple lumen), testing only one lumen from double catheters would have led to 27.2% of missed cases for CRBSIs. Additionally, testing only two or one lumen from triple lumen catheters would have led to 15.8% and 37.3% of missed cases for CRBSIs, respectively.
The study was limited by being conducted at a single test site and the need to withdraw catheters to perform endoluminal brushing and semi-quantitative techniques. Though diagnostic yield might significantly improve by culturing all multi-lumen sites, hospitalists should consider the time and cost expenditure for testing from more than one lumen.
Bottom line: Culturing all lumens from multi-lumen catheters could greatly increase diagnostic yield in CRBSIs.
Citation: Guembe M, Rodríguez-Créixems M, Sánchez-Carrillo C, Pérez-Parra A, Martín-Rabadán P, Bouza E. How many lumens should be cultured in the conservative diagnosis of catheter-related bloodstream infections? CID. 2010;50(12):1575-1579.
Early Anticoagulation Improves Survival after Acute PE
Clinical question: Does the timing of initial heparinization reduce mortality in patients with acute symptomatic PE?
Background: Acute PE is rapidly fatal if not diagnosed and treated. Studies have shown that intravenous heparin improves overall survival for patients with PE, and therapeutic anticoagulation reduces rates of recurrent VTE. However, studies investigating the relation between time to achieve therapeutic anticoagulation and mortality or PE recurrence are limited.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: From June 2002 and September 2005, 400 patients were identified with PE using retrospective data from Mayo Clinic’s electronic medical records. Patients who received heparin in the ED had lower in-hospital mortality (OR 0.20, 95% CI, 0.06-0.69) and 30-day mortality (OR 0.25, 95% CI, 0.12-0.55) compared with patients who received heparin after admission. Similarly, patients who achieved a therapeutic aPTT within 24 hours also had lower 30-day mortality (OR 0.34, 95% CI, 0.14-0.84). Patients with COPD and malignancies had higher in-hospital and 30-day mortality, respectively.
Bottom line: It is difficult to draw a causal relationship from a retrospective review, but hospitalists should start immediate anticoagulation therapy when a PE is suspected.
Citation: Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6): 1382-1390. TH
PEDIATRIC HM LITERATURE
Ibuprofen Use Associated with Complicated Pneumonia
Clinical question: What baseline characteristics are associated with suppurative complications in children hospitalized with community-acquired pneumonia?
Background: The prevalence of suppurative complications of community-acquired pneumonia (CAP) appears to be on the rise. Reasons for this increase remain unclear, although etiologic organism, older age, prior antibiotic, and nonsteroidal anti-inflammatory drug use have been implicated in a single prior retrospective study.
Study design: Retrospective cohort study.
Setting: Two hospitals in France.
Synopsis: Two physicians reviewed 1,184 charts based on ICD-10 discharge codes for pneumonia from 1995 to 2003. Children younger than 28 days and older than 15 years were excluded. Additionally, children with underlying or cardiorespiratory pathology were excluded. After applying predefined clinical criteria for pneumonia and suppurative complications, 677 children with CAP were compared to 90 with suppurative complications of pneumonia.
The incidence of suppurative complications increased to 13 per 100,000 from 0.5 per 100,000 over the time period. A minority of patients had etiologic microbes isolated, primarily Streptococcus pneumoniae, in both groups. Complicated pneumonia was more frequently seen in older children, and in children with prior antibiotic and anti-inflammatory medication use. After multivariable analysis, only ibuprofen use remained with an increased odds ratio (2.57, 95% confidence interval, 1.51-4.35) of complicated pneumonia.
The clear drawback of this study is an inability to draw a causal connection between ibuprofen use and the development of suppurative complications of pneumonia. The retrospective nature of the analysis further limits hypothesis generation. Nevertheless, it is notable that the results corroborate findings from a prior study in the U.S., in which ibuprofen was found to significantly increase the likelihood of parapneumonic empyema.
Bottom line: Ibuprofen use is associated with the development of suppurative complications of pneumonia.
Citation: François P, Desrumaux A, Cans C, Pin I, Pavese P, Labarère J. Prevalence and risk factors of suppurative complications in children with pneumonia. Acta Paediatr. 2010;99(6):861-866.
Market Watch
New Drugs, Devices, Indications, and Approvals
- Alglucosidase alfa (Lumizyme) has been approved by the FDA for the treatment of patients older than 8 with late (noninfantile) onset Pompe disease (GAA deficiency) who do not have evidence of cardiac hypertrophy.1
- Dutasteride and tamsulosin (Jalyn) has been approved by the FDA in a fixed-dose combination product for treating symptomatic benign prostatic hypertrophy.2
- Gatifloxacin ophthalmic solution 0.5% (Zymaxid) has been approved by the FDA to treat bacterial conjunctivitis caused by susceptible bacterial strains.3 It has the highest concentration of gatifloxacin ophthalmic on the U.S. market.
- Memantine hydrochloride (Namenda XR) has been approved by the FDA as an extended-release product to treat moderate to severe dementia of the Alzheimer's type.4 It is available as a 28 mg, once-daily dosage form. The immediate-release product is dosed twice daily.
- Mesenchymal stem cells for intravenous infusion (MSCs, Prochymal) formulated into Prochymal has been granted orphan drug status to treat Type 1 diabetes mellitus (T1DM).5 This agent is in Phase 2 clinical trials in a collaboration with the Juvenile Diabetes Research Foundation as a treatment for patients with newly diagnosed T1DM.
- Mometasone furoate/formoterol fumarate (Dulera) has been approved by the FDA as a combination treatment for asthmatics aged 12 and older.6
- Naproxen/esomeprazole (Vimovo) has been approved by the FDA as a fixed combination for patients with arthritis who are at risk for developing gastric ulcers.7
- Pioglitazone/metformin (ACTOplus met XR) has been approved by the FDA in an extended-release fixed combination for treating Type 2 diabetes mellitus (T2DM) as an adjunct to diet and exercise.8
- Ranibizumab (Lucentis) has received a new indication from the FDA for treating retinal vein occlusion.9 The original approval of ranibizumab was for wet age-related macular degeneration.
- Tramadol HCl, orally disintegrating tablets (Rybix ODT), have been approved by the FDA for treating moderate to moderately severe pain in patients 16 years of age and older.10
Pipeline
- Dronedarone (Multaq) is being investigated as to whether it can reduce major cardiovascular events in patients being treated with the agent for atrial fibrillation.11 Study endpoints will include a reduction in a major cardiovascular event such as stroke or myocardial infarction, or a reduction in cardiovascular hospitalization or death.
- The combination product ibuprofen and famotidine (to be known as Duexa) has been filed as a new drug application (NDA) for reducing the risk of developing upper gastrointestinal (GI) ulcers in patients with pain and arthritis.12 Two Phase 3 trials showed about a 50% reduction in GI ulcers in combination treatment compared with ibuprofen alone.
- Rifaximin (Xifaxan) has been submitted to the FDA at its higher dose (550 mg) for treatment of nonconstipation irritable bowel syndrome (Non-C-IBS) and IBS-related bloating.13 Rifaximin already has approval from the FDA for hepatic encephalopathy and diarrhea.
- TC-5214 has begun Phase 3 clinical trials.14 It is a nicotinic channel blocker for the adjunctive treatment of major depressive disorder in adults who have had an inadequate response to selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs). A Phase 2 study evaluating TC-5214 as a second-line (“switch”) monotherapy is planned for this year.
- An NDA for vilazodone has been filed for treating major depressive disorder.15 It is a dual-acting potent and selective serotonin reuptake inhibitor and a 5-HT1A receptor partial agonist.
Safety, Warnings, and Label Changes
- Tramadol and tramadol/acetaminophen have undergone a label change related to strengthened warnings of the risk of suicide for patients who are addiction-prone, taking tranquilizers, drinking alcohol, or taking other central-nervous-system-active drugs.16 Addictive effects might occur when tramadol is combined with alcohol, other opioids, or illicit drugs that have central-nervous-system-depressive effects. Serious potential consequences of overdosage are CNS and/or respiratory depression, and death.
- Earlier this year, the FDA once again updated the warning related to severe liver injury related to the use of propylthiouracil (PTU).17 This time, PTU has garnered a boxed warning, which includes reports of severe hepatotoxicity and acute liver failure in both adults and children. Some of these reactions were fatal. Use of PTU should be reserved for patients who do not tolerate other treatments for hyperthyroidism, such as methimazole, radioactive iodine, or are not surgery candidates. PTU might be preferred over methimazole just before and/or during the first trimester of pregnancy due to the occurrence of birth defects with methimazole during this timeframe. A medication guide has been developed and is to be given to patients when they fill PTU prescriptions. The guide alerts patients to the signs and symptoms of hepatotoxicity. TH
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
- Genzyme receives FDA approval for lumizyme for Pompe disease. Business Wire website. Available at: www.businesswire.com/portal/site/home/email/alert/?ndmViewId=news_view&newsLang=en&newsId=20100525006514. Accessed June 30, 2010.
- Dennis M. FDA approves GlaxoSmithKline’s combination BPH drug Jalyn. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=B5F703CADB0347DF970A7B7542D99982&logRowId=369156. Accessed June 30, 2010.
- Allergan receives FDA approval for Zymaxid ophthalmic solution. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/189397.php. Accessed June 29, 2010.
- Forest and Merz announce FDA approval of Namenda XR for the treatment of moderate to severe dementia of the Alzheimer’s type. Forest Laboratories website. Available at: http://www.frx.com/news/PressRelease.aspx?ID=1440385. Accessed June 30, 2010.
- Osiris Therapeutics receives FDA orphan drug designation for stem cell treatment for Type 1 diabetes. Osiris Therapeutics website. Available at: http://osiris.com/pdf/2010-05-04%20T1D%20Orphan%20Drug%20Designation.pdf. Accessed June 30, 2010.
- FDA approves Merck’s new lung drug Dulera. The Economic Times website. Available at: http://economictimes.indiatimes.com/articleshow/6087079.cms. Accessed June 30, 2010.
- Dane L. FDA approves AstraZeneca, Pozen’s Vimovo. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=0C2915EE4D2D47D287D41D90DFE4240D. Accessed June 30, 2010.
- ACTOplus met XR available for diabetes. Monthly Prescribing Reference website. Available at: http://www.empr.com/actoplus-met-xr-available-for-diabetes/article/172985/. Accessed June 30, 2010.
- Dennis M. Roche’s Lucentis garners expanded FDA approval for macular oedema. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=5146664F5A4C48108209D15EA744A614&logRowId=370643. Accessed June 30, 2010.
- Rybix ODT launched for moderate to moderately severe pain. Monthly Prescribing Reference website. Available at: http://www.empr.com/rybix-odt-launched-for-moderate-to-moderately-severe-pain/article/172743/. Accessed June 30, 3010.
- Dennis M. Sanofi-Aventis begins late-stage study of Multaq in patients with permanent AF. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E43104A2DB604649A812E69C58F89304&logRowId=364228. Accessed July 7, 2010.
- FDA accepts NDA for Duexa for ulcer risk reduction in arthritis patients. Monthly Prescribing Reference website. Available at: http://www.empr.com/fda-accepts-nda-for-duexa-for-ulcer-risk-reduction-in-arthritis-patients/article/171054/. Accessed July 7, 2010.
- Salix Pharmaceuticals announces NDA submission for Xifaxan550 for treatment of non-constipation irritable bowel syndrome. Salix Pharmaceuticals website. Available at: http://salix.com/news/stories/20100608.aspx. Accessed June 9, 2010.
- AstraZeneca and Targacept initiate Phase 3 clinical development of TC-5214 as an adjunct treatment for major depressive disorder. Targacept website. Available at: http://www.targacept.com/wt/page/pr_1277240993. Accessed June 29, 2010.
- Clinical Data, Inc. announces FDA acceptance of new drug application for Vilazodone for the treatment of major depressive disorder. Clinical Data Inc. website. Available at: http://clda.com/uploads/CLDA%20NDA%20acceptance%20FINAL.pdf. Accessed July 7, 2010.
- Ultram (tramadol hydrochloride), Ultracet (tramadol hydrochloride/acetaminophen): Label change. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm213264.htm. Accessed July 8, 2010.
- FDA Drug Safety Communication: New boxed warning on severe liver injury with propylthiouracil. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm209023.htm. Accessed July 8, 2010.
New Drugs, Devices, Indications, and Approvals
- Alglucosidase alfa (Lumizyme) has been approved by the FDA for the treatment of patients older than 8 with late (noninfantile) onset Pompe disease (GAA deficiency) who do not have evidence of cardiac hypertrophy.1
- Dutasteride and tamsulosin (Jalyn) has been approved by the FDA in a fixed-dose combination product for treating symptomatic benign prostatic hypertrophy.2
- Gatifloxacin ophthalmic solution 0.5% (Zymaxid) has been approved by the FDA to treat bacterial conjunctivitis caused by susceptible bacterial strains.3 It has the highest concentration of gatifloxacin ophthalmic on the U.S. market.
- Memantine hydrochloride (Namenda XR) has been approved by the FDA as an extended-release product to treat moderate to severe dementia of the Alzheimer's type.4 It is available as a 28 mg, once-daily dosage form. The immediate-release product is dosed twice daily.
- Mesenchymal stem cells for intravenous infusion (MSCs, Prochymal) formulated into Prochymal has been granted orphan drug status to treat Type 1 diabetes mellitus (T1DM).5 This agent is in Phase 2 clinical trials in a collaboration with the Juvenile Diabetes Research Foundation as a treatment for patients with newly diagnosed T1DM.
- Mometasone furoate/formoterol fumarate (Dulera) has been approved by the FDA as a combination treatment for asthmatics aged 12 and older.6
- Naproxen/esomeprazole (Vimovo) has been approved by the FDA as a fixed combination for patients with arthritis who are at risk for developing gastric ulcers.7
- Pioglitazone/metformin (ACTOplus met XR) has been approved by the FDA in an extended-release fixed combination for treating Type 2 diabetes mellitus (T2DM) as an adjunct to diet and exercise.8
- Ranibizumab (Lucentis) has received a new indication from the FDA for treating retinal vein occlusion.9 The original approval of ranibizumab was for wet age-related macular degeneration.
- Tramadol HCl, orally disintegrating tablets (Rybix ODT), have been approved by the FDA for treating moderate to moderately severe pain in patients 16 years of age and older.10
Pipeline
- Dronedarone (Multaq) is being investigated as to whether it can reduce major cardiovascular events in patients being treated with the agent for atrial fibrillation.11 Study endpoints will include a reduction in a major cardiovascular event such as stroke or myocardial infarction, or a reduction in cardiovascular hospitalization or death.
- The combination product ibuprofen and famotidine (to be known as Duexa) has been filed as a new drug application (NDA) for reducing the risk of developing upper gastrointestinal (GI) ulcers in patients with pain and arthritis.12 Two Phase 3 trials showed about a 50% reduction in GI ulcers in combination treatment compared with ibuprofen alone.
- Rifaximin (Xifaxan) has been submitted to the FDA at its higher dose (550 mg) for treatment of nonconstipation irritable bowel syndrome (Non-C-IBS) and IBS-related bloating.13 Rifaximin already has approval from the FDA for hepatic encephalopathy and diarrhea.
- TC-5214 has begun Phase 3 clinical trials.14 It is a nicotinic channel blocker for the adjunctive treatment of major depressive disorder in adults who have had an inadequate response to selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs). A Phase 2 study evaluating TC-5214 as a second-line (“switch”) monotherapy is planned for this year.
- An NDA for vilazodone has been filed for treating major depressive disorder.15 It is a dual-acting potent and selective serotonin reuptake inhibitor and a 5-HT1A receptor partial agonist.
Safety, Warnings, and Label Changes
- Tramadol and tramadol/acetaminophen have undergone a label change related to strengthened warnings of the risk of suicide for patients who are addiction-prone, taking tranquilizers, drinking alcohol, or taking other central-nervous-system-active drugs.16 Addictive effects might occur when tramadol is combined with alcohol, other opioids, or illicit drugs that have central-nervous-system-depressive effects. Serious potential consequences of overdosage are CNS and/or respiratory depression, and death.
- Earlier this year, the FDA once again updated the warning related to severe liver injury related to the use of propylthiouracil (PTU).17 This time, PTU has garnered a boxed warning, which includes reports of severe hepatotoxicity and acute liver failure in both adults and children. Some of these reactions were fatal. Use of PTU should be reserved for patients who do not tolerate other treatments for hyperthyroidism, such as methimazole, radioactive iodine, or are not surgery candidates. PTU might be preferred over methimazole just before and/or during the first trimester of pregnancy due to the occurrence of birth defects with methimazole during this timeframe. A medication guide has been developed and is to be given to patients when they fill PTU prescriptions. The guide alerts patients to the signs and symptoms of hepatotoxicity. TH
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
- Genzyme receives FDA approval for lumizyme for Pompe disease. Business Wire website. Available at: www.businesswire.com/portal/site/home/email/alert/?ndmViewId=news_view&newsLang=en&newsId=20100525006514. Accessed June 30, 2010.
- Dennis M. FDA approves GlaxoSmithKline’s combination BPH drug Jalyn. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=B5F703CADB0347DF970A7B7542D99982&logRowId=369156. Accessed June 30, 2010.
- Allergan receives FDA approval for Zymaxid ophthalmic solution. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/189397.php. Accessed June 29, 2010.
- Forest and Merz announce FDA approval of Namenda XR for the treatment of moderate to severe dementia of the Alzheimer’s type. Forest Laboratories website. Available at: http://www.frx.com/news/PressRelease.aspx?ID=1440385. Accessed June 30, 2010.
- Osiris Therapeutics receives FDA orphan drug designation for stem cell treatment for Type 1 diabetes. Osiris Therapeutics website. Available at: http://osiris.com/pdf/2010-05-04%20T1D%20Orphan%20Drug%20Designation.pdf. Accessed June 30, 2010.
- FDA approves Merck’s new lung drug Dulera. The Economic Times website. Available at: http://economictimes.indiatimes.com/articleshow/6087079.cms. Accessed June 30, 2010.
- Dane L. FDA approves AstraZeneca, Pozen’s Vimovo. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=0C2915EE4D2D47D287D41D90DFE4240D. Accessed June 30, 2010.
- ACTOplus met XR available for diabetes. Monthly Prescribing Reference website. Available at: http://www.empr.com/actoplus-met-xr-available-for-diabetes/article/172985/. Accessed June 30, 2010.
- Dennis M. Roche’s Lucentis garners expanded FDA approval for macular oedema. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=5146664F5A4C48108209D15EA744A614&logRowId=370643. Accessed June 30, 2010.
- Rybix ODT launched for moderate to moderately severe pain. Monthly Prescribing Reference website. Available at: http://www.empr.com/rybix-odt-launched-for-moderate-to-moderately-severe-pain/article/172743/. Accessed June 30, 3010.
- Dennis M. Sanofi-Aventis begins late-stage study of Multaq in patients with permanent AF. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E43104A2DB604649A812E69C58F89304&logRowId=364228. Accessed July 7, 2010.
- FDA accepts NDA for Duexa for ulcer risk reduction in arthritis patients. Monthly Prescribing Reference website. Available at: http://www.empr.com/fda-accepts-nda-for-duexa-for-ulcer-risk-reduction-in-arthritis-patients/article/171054/. Accessed July 7, 2010.
- Salix Pharmaceuticals announces NDA submission for Xifaxan550 for treatment of non-constipation irritable bowel syndrome. Salix Pharmaceuticals website. Available at: http://salix.com/news/stories/20100608.aspx. Accessed June 9, 2010.
- AstraZeneca and Targacept initiate Phase 3 clinical development of TC-5214 as an adjunct treatment for major depressive disorder. Targacept website. Available at: http://www.targacept.com/wt/page/pr_1277240993. Accessed June 29, 2010.
- Clinical Data, Inc. announces FDA acceptance of new drug application for Vilazodone for the treatment of major depressive disorder. Clinical Data Inc. website. Available at: http://clda.com/uploads/CLDA%20NDA%20acceptance%20FINAL.pdf. Accessed July 7, 2010.
- Ultram (tramadol hydrochloride), Ultracet (tramadol hydrochloride/acetaminophen): Label change. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm213264.htm. Accessed July 8, 2010.
- FDA Drug Safety Communication: New boxed warning on severe liver injury with propylthiouracil. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm209023.htm. Accessed July 8, 2010.
New Drugs, Devices, Indications, and Approvals
- Alglucosidase alfa (Lumizyme) has been approved by the FDA for the treatment of patients older than 8 with late (noninfantile) onset Pompe disease (GAA deficiency) who do not have evidence of cardiac hypertrophy.1
- Dutasteride and tamsulosin (Jalyn) has been approved by the FDA in a fixed-dose combination product for treating symptomatic benign prostatic hypertrophy.2
- Gatifloxacin ophthalmic solution 0.5% (Zymaxid) has been approved by the FDA to treat bacterial conjunctivitis caused by susceptible bacterial strains.3 It has the highest concentration of gatifloxacin ophthalmic on the U.S. market.
- Memantine hydrochloride (Namenda XR) has been approved by the FDA as an extended-release product to treat moderate to severe dementia of the Alzheimer's type.4 It is available as a 28 mg, once-daily dosage form. The immediate-release product is dosed twice daily.
- Mesenchymal stem cells for intravenous infusion (MSCs, Prochymal) formulated into Prochymal has been granted orphan drug status to treat Type 1 diabetes mellitus (T1DM).5 This agent is in Phase 2 clinical trials in a collaboration with the Juvenile Diabetes Research Foundation as a treatment for patients with newly diagnosed T1DM.
- Mometasone furoate/formoterol fumarate (Dulera) has been approved by the FDA as a combination treatment for asthmatics aged 12 and older.6
- Naproxen/esomeprazole (Vimovo) has been approved by the FDA as a fixed combination for patients with arthritis who are at risk for developing gastric ulcers.7
- Pioglitazone/metformin (ACTOplus met XR) has been approved by the FDA in an extended-release fixed combination for treating Type 2 diabetes mellitus (T2DM) as an adjunct to diet and exercise.8
- Ranibizumab (Lucentis) has received a new indication from the FDA for treating retinal vein occlusion.9 The original approval of ranibizumab was for wet age-related macular degeneration.
- Tramadol HCl, orally disintegrating tablets (Rybix ODT), have been approved by the FDA for treating moderate to moderately severe pain in patients 16 years of age and older.10
Pipeline
- Dronedarone (Multaq) is being investigated as to whether it can reduce major cardiovascular events in patients being treated with the agent for atrial fibrillation.11 Study endpoints will include a reduction in a major cardiovascular event such as stroke or myocardial infarction, or a reduction in cardiovascular hospitalization or death.
- The combination product ibuprofen and famotidine (to be known as Duexa) has been filed as a new drug application (NDA) for reducing the risk of developing upper gastrointestinal (GI) ulcers in patients with pain and arthritis.12 Two Phase 3 trials showed about a 50% reduction in GI ulcers in combination treatment compared with ibuprofen alone.
- Rifaximin (Xifaxan) has been submitted to the FDA at its higher dose (550 mg) for treatment of nonconstipation irritable bowel syndrome (Non-C-IBS) and IBS-related bloating.13 Rifaximin already has approval from the FDA for hepatic encephalopathy and diarrhea.
- TC-5214 has begun Phase 3 clinical trials.14 It is a nicotinic channel blocker for the adjunctive treatment of major depressive disorder in adults who have had an inadequate response to selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs). A Phase 2 study evaluating TC-5214 as a second-line (“switch”) monotherapy is planned for this year.
- An NDA for vilazodone has been filed for treating major depressive disorder.15 It is a dual-acting potent and selective serotonin reuptake inhibitor and a 5-HT1A receptor partial agonist.
Safety, Warnings, and Label Changes
- Tramadol and tramadol/acetaminophen have undergone a label change related to strengthened warnings of the risk of suicide for patients who are addiction-prone, taking tranquilizers, drinking alcohol, or taking other central-nervous-system-active drugs.16 Addictive effects might occur when tramadol is combined with alcohol, other opioids, or illicit drugs that have central-nervous-system-depressive effects. Serious potential consequences of overdosage are CNS and/or respiratory depression, and death.
- Earlier this year, the FDA once again updated the warning related to severe liver injury related to the use of propylthiouracil (PTU).17 This time, PTU has garnered a boxed warning, which includes reports of severe hepatotoxicity and acute liver failure in both adults and children. Some of these reactions were fatal. Use of PTU should be reserved for patients who do not tolerate other treatments for hyperthyroidism, such as methimazole, radioactive iodine, or are not surgery candidates. PTU might be preferred over methimazole just before and/or during the first trimester of pregnancy due to the occurrence of birth defects with methimazole during this timeframe. A medication guide has been developed and is to be given to patients when they fill PTU prescriptions. The guide alerts patients to the signs and symptoms of hepatotoxicity. TH
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
- Genzyme receives FDA approval for lumizyme for Pompe disease. Business Wire website. Available at: www.businesswire.com/portal/site/home/email/alert/?ndmViewId=news_view&newsLang=en&newsId=20100525006514. Accessed June 30, 2010.
- Dennis M. FDA approves GlaxoSmithKline’s combination BPH drug Jalyn. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=B5F703CADB0347DF970A7B7542D99982&logRowId=369156. Accessed June 30, 2010.
- Allergan receives FDA approval for Zymaxid ophthalmic solution. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/189397.php. Accessed June 29, 2010.
- Forest and Merz announce FDA approval of Namenda XR for the treatment of moderate to severe dementia of the Alzheimer’s type. Forest Laboratories website. Available at: http://www.frx.com/news/PressRelease.aspx?ID=1440385. Accessed June 30, 2010.
- Osiris Therapeutics receives FDA orphan drug designation for stem cell treatment for Type 1 diabetes. Osiris Therapeutics website. Available at: http://osiris.com/pdf/2010-05-04%20T1D%20Orphan%20Drug%20Designation.pdf. Accessed June 30, 2010.
- FDA approves Merck’s new lung drug Dulera. The Economic Times website. Available at: http://economictimes.indiatimes.com/articleshow/6087079.cms. Accessed June 30, 2010.
- Dane L. FDA approves AstraZeneca, Pozen’s Vimovo. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=0C2915EE4D2D47D287D41D90DFE4240D. Accessed June 30, 2010.
- ACTOplus met XR available for diabetes. Monthly Prescribing Reference website. Available at: http://www.empr.com/actoplus-met-xr-available-for-diabetes/article/172985/. Accessed June 30, 2010.
- Dennis M. Roche’s Lucentis garners expanded FDA approval for macular oedema. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=5146664F5A4C48108209D15EA744A614&logRowId=370643. Accessed June 30, 2010.
- Rybix ODT launched for moderate to moderately severe pain. Monthly Prescribing Reference website. Available at: http://www.empr.com/rybix-odt-launched-for-moderate-to-moderately-severe-pain/article/172743/. Accessed June 30, 3010.
- Dennis M. Sanofi-Aventis begins late-stage study of Multaq in patients with permanent AF. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E43104A2DB604649A812E69C58F89304&logRowId=364228. Accessed July 7, 2010.
- FDA accepts NDA for Duexa for ulcer risk reduction in arthritis patients. Monthly Prescribing Reference website. Available at: http://www.empr.com/fda-accepts-nda-for-duexa-for-ulcer-risk-reduction-in-arthritis-patients/article/171054/. Accessed July 7, 2010.
- Salix Pharmaceuticals announces NDA submission for Xifaxan550 for treatment of non-constipation irritable bowel syndrome. Salix Pharmaceuticals website. Available at: http://salix.com/news/stories/20100608.aspx. Accessed June 9, 2010.
- AstraZeneca and Targacept initiate Phase 3 clinical development of TC-5214 as an adjunct treatment for major depressive disorder. Targacept website. Available at: http://www.targacept.com/wt/page/pr_1277240993. Accessed June 29, 2010.
- Clinical Data, Inc. announces FDA acceptance of new drug application for Vilazodone for the treatment of major depressive disorder. Clinical Data Inc. website. Available at: http://clda.com/uploads/CLDA%20NDA%20acceptance%20FINAL.pdf. Accessed July 7, 2010.
- Ultram (tramadol hydrochloride), Ultracet (tramadol hydrochloride/acetaminophen): Label change. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm213264.htm. Accessed July 8, 2010.
- FDA Drug Safety Communication: New boxed warning on severe liver injury with propylthiouracil. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm209023.htm. Accessed July 8, 2010.
A Taxing Future for HM?
When Congress returns for a likely lame-duck session after the midterm elections, the biggest battle might be fought over whether to extend the 2001 and 2003 tax cuts to everyone or only to those earning less than $200,000 annually ($250,000 for families). And depending on the makeup of the 112th Congress, which will be seated in January, Republicans might try to make good on a campaign pledge to repeal all or most of the healthcare reform legislation.
The expected flashpoints are being teased endlessly with media sound bites featuring phrases that most of us love to hate: higher taxes, spiraling medical bills, soaring insurance premiums. Insurance companies already are blaming a spike in premiums on the healthcare legislation, claiming that new provisions and mandates are forcing them to further hike their rates.
Closer to home, the high-profile frays could put hospitalists in the awkward position of supporting political positions that sock them in the wallet. After all, doctors are workers and healthcare consumers, too. So what impact could higher taxes and higher insurance premiums really have? Let’s start with health insurance.
Insurance Cost Increases
Signed into law in March, the Affordable Care Act includes tax credits for small businesses to help defray the costs of health insurance coverage. But in 2013, it also raises the threshold for medical expense deductions for most taxpayers, to 10% from 7.5% of adjusted gross income. In other words, families can claim tax deductions only after having spent 10% or more of their adjusted gross income on medical bills. For families with hefty medical bills, that 2.5% difference could translate into a significant shortfall.
CMS was able to negotiate with insurers to achieve a slight drop in Medicare Advantage premiums, but many individual states have had less luck in preventing rate increases from private insurers who blame their higher premiums on new mandates. The Wall Street Journal has documented rate increases of 18% in states like Wisconsin and North Carolina—about 9% of which insurance company officials pinned on the new law.1 Such increases are hardly inevitable, however. The Obama administration’s White House blog, for instance, has cited the example of North Carolina Blue Cross and Blue Shield, which announced Sept. 20 that it will provide $156 million in refunds to more than 215,000 customers after state regulators found an overcharge that should be reversed due to new rules in the reform law.2 WellPoint will similarly refund $20 million to its health insurance customers in Colorado.2
The requested premium increases and identified overcharges have contributed to plenty of finger-pointing among insurers, state regulators, and the Obama administration, which has assailed insurers for using the law as a convenient excuse to raise rates. Highlighting the unease of many consumers, however, is the verdict that the proposed increases—if approved—would hit small businesses and individuals hardest.
According to the State of Hospital Medicine: 2010 Report Based on 2009 Data, released in September by SHM and the Medical Group Management Association, participating hospitalist groups have a median of 10 physician full-time equivalents. Roughly 25% of respondents are in physician-owned groups, while 14% are in a management services organization (MSO) or physician practice management company (PPMC). Smaller HM groups wouldn’t be alone in feeling the pinch, but they might need to consider some serious comparison-shopping to avoid costly premium increases.
Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., has worked with healthcare systems and providers in 42 states, but even her company has not been immune to having to contend with rising premiums. “Our managing partner just renegotiated our health benefits [premiums] that were supposed to have gone up 30% by our previous carrier,” Murer says. “Through protracted negotiations and diligence, he was able to find a plan that did not increase our costs, and retained pretty much the same benefits.”
For at least the next three to five years, Murer says, niche firms will need to be diligent about shopping around and managing their expenses in a volatile insurance marketplace. Healthcare reform, she says, is certainly not a panacea for reining in costs, but “just the beginning.”
Concerns over healthcare costs, in fact, could be among the factors driving what Robert Zipper, MD, FHM, regional chief medical officer for Tacoma, Wash.-based Sound Physicians, sees as continuing consolidation among hospitalist groups. “By that, I mean that either groups are swallowed up by the hospital in which they work or they become part of a regional or national company,” he says. Sound Physicians, with about 400 hospitalists in seven states, offers health insurance policies that don’t vary by state, easing its negotiations.
Eyes on the Bottom Line
What about the dreaded “T” word? Dr. Zipper says he hasn’t heard that many concerns about the potential tax increase just yet. “I think it’s not an issue to hospitalists in a broad sense yet,” he says, “but if you look at the salary trajectory and where things have been over the past 10 years, it’s pretty easy to predict that it will be an issue for single-income [households] where the hospitalist is the sole breadwinner.”
The 2010 State of Hospital Medicine report, which surveyed 4,211 nonacademic hospitalists from 443 groups, found a median annual income of $215,000. Calculating trends from past income surveys is difficult due to very different respondent populations, but many hospitalists are clearly near or above the $200,000 threshold for individuals and near the $250,000 threshold for families already, even before considering spousal income. The survey, for example, found median salaries of about $235,700 in the 13 states that make up the Southern region.
Even if higher-earning hospitalists are subjected to a higher tax rate next year—if the current rates expire, a climb of 4.6 percentage points, to 39.6% from 35%—not all of them are necessarily opposed to it. Political polling on the issue isn’t broken down by specific professions, but a number of blogs have pointed to a Quinnipiac University poll conducted back in March that suggested nearly two-thirds of upper-income Americans were prepared to sacrifice some of their take-home pay to help reduce the deficit. In that poll (www.quinnipiac.edu/x1295.xml?ReleaseID=1438), some 64% of respondents earning more than $250,000 agreed that raising income taxes on themselves and other households making more than $250,000 should be a main part of any government approach to the deficit.
If taxes and insurance premiums are more immediate concerns, some HM observers are eyeing longer trends that could impact the pre-tax pay of the profession. Most hospitalists still earn far less than their specialist counterparts, of course, but increasing demand for hospitalist services has helped fuel a rise in median salaries. Last year, some observers predicted that after an impressive run, annual pay would plateau or even fall, given the current economic uncertainty, tightening profit margins, and assessment that many hospitals run HM programs at a loss.3 And in the current RVU-driven system, the “What have you done for me lately?” mentality can indeed make it difficult for hospitalists to demonstrate a solid return on the investment.
The State of Hospital Medicine report suggests that respondent HM groups have been subsidized by an average of $111,486 per physician FTE (median is $98,253), with the highest numbers in hospital-owned practices. But many experts see a window of a few years in which new healthcare delivery and payment experiments will be trotted out, whether modeled on a bundled system, accountable-care organization (ACO), or other vehicle. Under these models, payment incentives to physicians—and to hospitalists especially—could be fundamentally restructured to better reflect their true contributions as the emphasis on quality and efficiency increases.
Within the next three years, Murer says, hospitalists need to continue to infiltrate inpatient medical services, demonstrate their worth, and show the cost efficiencies that arise from their profession. “I think they’ve got a window of three years to really decide how much of that [inpatient physician] market they will retain,” she says.
Despite the current volatility, both Murer and Dr. Zipper agree that hospitalists are well positioned to take advantage of the coming changes in the healthcare delivery system. But to seize the opportunity, hospitalists must clearly demonstrate the necessity of their services in the emerging models of care and claim an early seat at the table where decisions will be made about how the pot of money is dispersed. Doing so could help resolve one of the most important financial considerations of all: job security. TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Adamy J. Health insurers plan hikes. Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052748703720004575478200948908976.html. Accessed Sept. 21, 2010.
- Cutter S. Look you in the eye. The White House website. Available at: www.whitehouse.gov/blog/2010/09/23/look-you-eye. Accessed Sept. 27, 2010.
- How will the economy affect hospitalist salaries? MedPage Today website. Available at: www.kevinmd .com/blog/2009/03/how-will-economy-affect-hospitalist-2.html. Accessed Sept. 27, 2010.
When Congress returns for a likely lame-duck session after the midterm elections, the biggest battle might be fought over whether to extend the 2001 and 2003 tax cuts to everyone or only to those earning less than $200,000 annually ($250,000 for families). And depending on the makeup of the 112th Congress, which will be seated in January, Republicans might try to make good on a campaign pledge to repeal all or most of the healthcare reform legislation.
The expected flashpoints are being teased endlessly with media sound bites featuring phrases that most of us love to hate: higher taxes, spiraling medical bills, soaring insurance premiums. Insurance companies already are blaming a spike in premiums on the healthcare legislation, claiming that new provisions and mandates are forcing them to further hike their rates.
Closer to home, the high-profile frays could put hospitalists in the awkward position of supporting political positions that sock them in the wallet. After all, doctors are workers and healthcare consumers, too. So what impact could higher taxes and higher insurance premiums really have? Let’s start with health insurance.
Insurance Cost Increases
Signed into law in March, the Affordable Care Act includes tax credits for small businesses to help defray the costs of health insurance coverage. But in 2013, it also raises the threshold for medical expense deductions for most taxpayers, to 10% from 7.5% of adjusted gross income. In other words, families can claim tax deductions only after having spent 10% or more of their adjusted gross income on medical bills. For families with hefty medical bills, that 2.5% difference could translate into a significant shortfall.
CMS was able to negotiate with insurers to achieve a slight drop in Medicare Advantage premiums, but many individual states have had less luck in preventing rate increases from private insurers who blame their higher premiums on new mandates. The Wall Street Journal has documented rate increases of 18% in states like Wisconsin and North Carolina—about 9% of which insurance company officials pinned on the new law.1 Such increases are hardly inevitable, however. The Obama administration’s White House blog, for instance, has cited the example of North Carolina Blue Cross and Blue Shield, which announced Sept. 20 that it will provide $156 million in refunds to more than 215,000 customers after state regulators found an overcharge that should be reversed due to new rules in the reform law.2 WellPoint will similarly refund $20 million to its health insurance customers in Colorado.2
The requested premium increases and identified overcharges have contributed to plenty of finger-pointing among insurers, state regulators, and the Obama administration, which has assailed insurers for using the law as a convenient excuse to raise rates. Highlighting the unease of many consumers, however, is the verdict that the proposed increases—if approved—would hit small businesses and individuals hardest.
According to the State of Hospital Medicine: 2010 Report Based on 2009 Data, released in September by SHM and the Medical Group Management Association, participating hospitalist groups have a median of 10 physician full-time equivalents. Roughly 25% of respondents are in physician-owned groups, while 14% are in a management services organization (MSO) or physician practice management company (PPMC). Smaller HM groups wouldn’t be alone in feeling the pinch, but they might need to consider some serious comparison-shopping to avoid costly premium increases.
Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., has worked with healthcare systems and providers in 42 states, but even her company has not been immune to having to contend with rising premiums. “Our managing partner just renegotiated our health benefits [premiums] that were supposed to have gone up 30% by our previous carrier,” Murer says. “Through protracted negotiations and diligence, he was able to find a plan that did not increase our costs, and retained pretty much the same benefits.”
For at least the next three to five years, Murer says, niche firms will need to be diligent about shopping around and managing their expenses in a volatile insurance marketplace. Healthcare reform, she says, is certainly not a panacea for reining in costs, but “just the beginning.”
Concerns over healthcare costs, in fact, could be among the factors driving what Robert Zipper, MD, FHM, regional chief medical officer for Tacoma, Wash.-based Sound Physicians, sees as continuing consolidation among hospitalist groups. “By that, I mean that either groups are swallowed up by the hospital in which they work or they become part of a regional or national company,” he says. Sound Physicians, with about 400 hospitalists in seven states, offers health insurance policies that don’t vary by state, easing its negotiations.
Eyes on the Bottom Line
What about the dreaded “T” word? Dr. Zipper says he hasn’t heard that many concerns about the potential tax increase just yet. “I think it’s not an issue to hospitalists in a broad sense yet,” he says, “but if you look at the salary trajectory and where things have been over the past 10 years, it’s pretty easy to predict that it will be an issue for single-income [households] where the hospitalist is the sole breadwinner.”
The 2010 State of Hospital Medicine report, which surveyed 4,211 nonacademic hospitalists from 443 groups, found a median annual income of $215,000. Calculating trends from past income surveys is difficult due to very different respondent populations, but many hospitalists are clearly near or above the $200,000 threshold for individuals and near the $250,000 threshold for families already, even before considering spousal income. The survey, for example, found median salaries of about $235,700 in the 13 states that make up the Southern region.
Even if higher-earning hospitalists are subjected to a higher tax rate next year—if the current rates expire, a climb of 4.6 percentage points, to 39.6% from 35%—not all of them are necessarily opposed to it. Political polling on the issue isn’t broken down by specific professions, but a number of blogs have pointed to a Quinnipiac University poll conducted back in March that suggested nearly two-thirds of upper-income Americans were prepared to sacrifice some of their take-home pay to help reduce the deficit. In that poll (www.quinnipiac.edu/x1295.xml?ReleaseID=1438), some 64% of respondents earning more than $250,000 agreed that raising income taxes on themselves and other households making more than $250,000 should be a main part of any government approach to the deficit.
If taxes and insurance premiums are more immediate concerns, some HM observers are eyeing longer trends that could impact the pre-tax pay of the profession. Most hospitalists still earn far less than their specialist counterparts, of course, but increasing demand for hospitalist services has helped fuel a rise in median salaries. Last year, some observers predicted that after an impressive run, annual pay would plateau or even fall, given the current economic uncertainty, tightening profit margins, and assessment that many hospitals run HM programs at a loss.3 And in the current RVU-driven system, the “What have you done for me lately?” mentality can indeed make it difficult for hospitalists to demonstrate a solid return on the investment.
The State of Hospital Medicine report suggests that respondent HM groups have been subsidized by an average of $111,486 per physician FTE (median is $98,253), with the highest numbers in hospital-owned practices. But many experts see a window of a few years in which new healthcare delivery and payment experiments will be trotted out, whether modeled on a bundled system, accountable-care organization (ACO), or other vehicle. Under these models, payment incentives to physicians—and to hospitalists especially—could be fundamentally restructured to better reflect their true contributions as the emphasis on quality and efficiency increases.
Within the next three years, Murer says, hospitalists need to continue to infiltrate inpatient medical services, demonstrate their worth, and show the cost efficiencies that arise from their profession. “I think they’ve got a window of three years to really decide how much of that [inpatient physician] market they will retain,” she says.
Despite the current volatility, both Murer and Dr. Zipper agree that hospitalists are well positioned to take advantage of the coming changes in the healthcare delivery system. But to seize the opportunity, hospitalists must clearly demonstrate the necessity of their services in the emerging models of care and claim an early seat at the table where decisions will be made about how the pot of money is dispersed. Doing so could help resolve one of the most important financial considerations of all: job security. TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Adamy J. Health insurers plan hikes. Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052748703720004575478200948908976.html. Accessed Sept. 21, 2010.
- Cutter S. Look you in the eye. The White House website. Available at: www.whitehouse.gov/blog/2010/09/23/look-you-eye. Accessed Sept. 27, 2010.
- How will the economy affect hospitalist salaries? MedPage Today website. Available at: www.kevinmd .com/blog/2009/03/how-will-economy-affect-hospitalist-2.html. Accessed Sept. 27, 2010.
When Congress returns for a likely lame-duck session after the midterm elections, the biggest battle might be fought over whether to extend the 2001 and 2003 tax cuts to everyone or only to those earning less than $200,000 annually ($250,000 for families). And depending on the makeup of the 112th Congress, which will be seated in January, Republicans might try to make good on a campaign pledge to repeal all or most of the healthcare reform legislation.
The expected flashpoints are being teased endlessly with media sound bites featuring phrases that most of us love to hate: higher taxes, spiraling medical bills, soaring insurance premiums. Insurance companies already are blaming a spike in premiums on the healthcare legislation, claiming that new provisions and mandates are forcing them to further hike their rates.
Closer to home, the high-profile frays could put hospitalists in the awkward position of supporting political positions that sock them in the wallet. After all, doctors are workers and healthcare consumers, too. So what impact could higher taxes and higher insurance premiums really have? Let’s start with health insurance.
Insurance Cost Increases
Signed into law in March, the Affordable Care Act includes tax credits for small businesses to help defray the costs of health insurance coverage. But in 2013, it also raises the threshold for medical expense deductions for most taxpayers, to 10% from 7.5% of adjusted gross income. In other words, families can claim tax deductions only after having spent 10% or more of their adjusted gross income on medical bills. For families with hefty medical bills, that 2.5% difference could translate into a significant shortfall.
CMS was able to negotiate with insurers to achieve a slight drop in Medicare Advantage premiums, but many individual states have had less luck in preventing rate increases from private insurers who blame their higher premiums on new mandates. The Wall Street Journal has documented rate increases of 18% in states like Wisconsin and North Carolina—about 9% of which insurance company officials pinned on the new law.1 Such increases are hardly inevitable, however. The Obama administration’s White House blog, for instance, has cited the example of North Carolina Blue Cross and Blue Shield, which announced Sept. 20 that it will provide $156 million in refunds to more than 215,000 customers after state regulators found an overcharge that should be reversed due to new rules in the reform law.2 WellPoint will similarly refund $20 million to its health insurance customers in Colorado.2
The requested premium increases and identified overcharges have contributed to plenty of finger-pointing among insurers, state regulators, and the Obama administration, which has assailed insurers for using the law as a convenient excuse to raise rates. Highlighting the unease of many consumers, however, is the verdict that the proposed increases—if approved—would hit small businesses and individuals hardest.
According to the State of Hospital Medicine: 2010 Report Based on 2009 Data, released in September by SHM and the Medical Group Management Association, participating hospitalist groups have a median of 10 physician full-time equivalents. Roughly 25% of respondents are in physician-owned groups, while 14% are in a management services organization (MSO) or physician practice management company (PPMC). Smaller HM groups wouldn’t be alone in feeling the pinch, but they might need to consider some serious comparison-shopping to avoid costly premium increases.
Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., has worked with healthcare systems and providers in 42 states, but even her company has not been immune to having to contend with rising premiums. “Our managing partner just renegotiated our health benefits [premiums] that were supposed to have gone up 30% by our previous carrier,” Murer says. “Through protracted negotiations and diligence, he was able to find a plan that did not increase our costs, and retained pretty much the same benefits.”
For at least the next three to five years, Murer says, niche firms will need to be diligent about shopping around and managing their expenses in a volatile insurance marketplace. Healthcare reform, she says, is certainly not a panacea for reining in costs, but “just the beginning.”
Concerns over healthcare costs, in fact, could be among the factors driving what Robert Zipper, MD, FHM, regional chief medical officer for Tacoma, Wash.-based Sound Physicians, sees as continuing consolidation among hospitalist groups. “By that, I mean that either groups are swallowed up by the hospital in which they work or they become part of a regional or national company,” he says. Sound Physicians, with about 400 hospitalists in seven states, offers health insurance policies that don’t vary by state, easing its negotiations.
Eyes on the Bottom Line
What about the dreaded “T” word? Dr. Zipper says he hasn’t heard that many concerns about the potential tax increase just yet. “I think it’s not an issue to hospitalists in a broad sense yet,” he says, “but if you look at the salary trajectory and where things have been over the past 10 years, it’s pretty easy to predict that it will be an issue for single-income [households] where the hospitalist is the sole breadwinner.”
The 2010 State of Hospital Medicine report, which surveyed 4,211 nonacademic hospitalists from 443 groups, found a median annual income of $215,000. Calculating trends from past income surveys is difficult due to very different respondent populations, but many hospitalists are clearly near or above the $200,000 threshold for individuals and near the $250,000 threshold for families already, even before considering spousal income. The survey, for example, found median salaries of about $235,700 in the 13 states that make up the Southern region.
Even if higher-earning hospitalists are subjected to a higher tax rate next year—if the current rates expire, a climb of 4.6 percentage points, to 39.6% from 35%—not all of them are necessarily opposed to it. Political polling on the issue isn’t broken down by specific professions, but a number of blogs have pointed to a Quinnipiac University poll conducted back in March that suggested nearly two-thirds of upper-income Americans were prepared to sacrifice some of their take-home pay to help reduce the deficit. In that poll (www.quinnipiac.edu/x1295.xml?ReleaseID=1438), some 64% of respondents earning more than $250,000 agreed that raising income taxes on themselves and other households making more than $250,000 should be a main part of any government approach to the deficit.
If taxes and insurance premiums are more immediate concerns, some HM observers are eyeing longer trends that could impact the pre-tax pay of the profession. Most hospitalists still earn far less than their specialist counterparts, of course, but increasing demand for hospitalist services has helped fuel a rise in median salaries. Last year, some observers predicted that after an impressive run, annual pay would plateau or even fall, given the current economic uncertainty, tightening profit margins, and assessment that many hospitals run HM programs at a loss.3 And in the current RVU-driven system, the “What have you done for me lately?” mentality can indeed make it difficult for hospitalists to demonstrate a solid return on the investment.
The State of Hospital Medicine report suggests that respondent HM groups have been subsidized by an average of $111,486 per physician FTE (median is $98,253), with the highest numbers in hospital-owned practices. But many experts see a window of a few years in which new healthcare delivery and payment experiments will be trotted out, whether modeled on a bundled system, accountable-care organization (ACO), or other vehicle. Under these models, payment incentives to physicians—and to hospitalists especially—could be fundamentally restructured to better reflect their true contributions as the emphasis on quality and efficiency increases.
Within the next three years, Murer says, hospitalists need to continue to infiltrate inpatient medical services, demonstrate their worth, and show the cost efficiencies that arise from their profession. “I think they’ve got a window of three years to really decide how much of that [inpatient physician] market they will retain,” she says.
Despite the current volatility, both Murer and Dr. Zipper agree that hospitalists are well positioned to take advantage of the coming changes in the healthcare delivery system. But to seize the opportunity, hospitalists must clearly demonstrate the necessity of their services in the emerging models of care and claim an early seat at the table where decisions will be made about how the pot of money is dispersed. Doing so could help resolve one of the most important financial considerations of all: job security. TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Adamy J. Health insurers plan hikes. Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052748703720004575478200948908976.html. Accessed Sept. 21, 2010.
- Cutter S. Look you in the eye. The White House website. Available at: www.whitehouse.gov/blog/2010/09/23/look-you-eye. Accessed Sept. 27, 2010.
- How will the economy affect hospitalist salaries? MedPage Today website. Available at: www.kevinmd .com/blog/2009/03/how-will-economy-affect-hospitalist-2.html. Accessed Sept. 27, 2010.
Background Checks
If the hospitalist recruitment process is a puzzle, then the background check is the vacuum cleaner, sweeping the area for any missing puzzle pieces.
“You are trying to get the whole picture,” Tim Lary, vice president of physician staffing at North Hollywood, Calif.-based IPC: The Hospitalist Company, says. “You are trying to see if something doesn’t fit right.”
Any competent healthcare organization will conduct a background check on hospitalist job candidates, first and foremost to ensure patient safety and a safe practice environment for other healthcare providers, Lary says. There also is the issue of liability.
Financial liability for the negative acts of employees, whether accidental or intentional, is an area of exposure for businesses, says Les Rosen, president and CEO of Employment Screening Resources, a consumer reporting agency and human resources consulting firm in Novato, Calif. Businesses can be held liable for injuries resulting from the failure to adequately screen the people it hires. Background checks demonstrate the organization has done its due diligence in assessing the safety and competence of job candidates.
“It enables an organization to hire based upon facts, not just instincts,” Rosen says.
Background Basics
Hospitalists must be prepared to effectively deal with background checks throughout their professional careers. Employment checks often involve three areas: credentials verification, reference checking, and an additional background investigation.
Credentialing includes a review of the hospitalist’s completed education, training, residency, licenses, and any certifications, and often encompasses the candidate’s hospital privileges history, malpractice claims history, and peer reviews.
Reference checking involves verifying dates of employment and title at the hospitalist’s previous jobs, and contacting references to speak with them about the candidate’s qualifications.
Background investigations often are done by a third-party agency. The investigation will vary depending on the policies of the healthcare organization contracting the review, but, generally speaking, it includes a check of the following:
- Criminal and civil court records for criminal convictions, arrests, and lawsuits;
- Motor vehicle records and driver record status;
- The National Practitioner Data Bank for malpractice cases and medical board sanctions;
- Medicare sanction list of the Office of Inspector General in the U.S. Department of Health and Human Services;
- Social Security number; and
- Sex offender and terrorist databases.
Some investigations will include credit checks, which can cover credit payment history, bankruptcies, tax liens, and accounts placed into collections.
It is illegal during a background check to search for information related to a job candidate’s race, age, religion, sexual orientation, or any other protected category under the federal Civil Rights Act, says Cheryl Slack, vice president of human resources at Brentwood, Tenn.-based Cogent Healthcare.
Under the federal Fair Credit Reporting Act (www.ftc.gov/os/statutes/031224fcra.pdf), it also is illegal for a third-party consumer-reporting agency to perform an employment background check in secret, Rosen says. The applicant must authorize the check by signing a standalone disclosure form, he says. For the rare healthcare organizations that do their background checks in-house, most will seek consent.
Disclosure Is Crucial
Hospitalist job candidates should do whatever they can to make sure the people in charge of hiring aren’t surprised by what turns up in a background check, the experts say. “Nothing is more frustrating than finding out there is a problem late in the application process,” Lary says.
Hospitalists should inform the references they list on their resumes that they could be contacted. Such a “heads up” often gives a reference time to organize their thoughts about the job applicant and provide the best possible recommendation.
“You would be shocked at how many references are surprised to learn the hospitalist is looking for a job or how many applicants give as references people who don’t like them personally or professionally,” Lary says. “There are even times when physicians will take a pass on a reference. That speaks volumes.”
The most important thing a candidate should know is if there is something negative in their background that could be professionally damaging if discovered. It is best to make the people hiring aware of the information, Rosen says.
“Disclosure is best 100% of the time,” says Reuben Tovar, MD, chairman of Hospital Internists of Austin, a physician-owned and -managed hospitalist practice in Texas. “To deny or not include something on a resume or in an interview makes it look like you are a liar, or haven’t come to terms with what happened.”
The main impediment to disclosure is embarrassment and shame, says Dr. Tovar, who has encountered a number of physician candidates who have had problems. Those who disclose past issues are in a much better position to explain the situation and show how they have cleaned up a messy situation.
“Physicians are generally willing to at least consider giving their colleagues a second chance in employment and [hospital] credentialing if they are forthright,” Dr. Tovar says. “Not being forthright is an automatic exclusion.” TH
Lisa Ryan is a freelance writer based in New Jersey.
If the hospitalist recruitment process is a puzzle, then the background check is the vacuum cleaner, sweeping the area for any missing puzzle pieces.
“You are trying to get the whole picture,” Tim Lary, vice president of physician staffing at North Hollywood, Calif.-based IPC: The Hospitalist Company, says. “You are trying to see if something doesn’t fit right.”
Any competent healthcare organization will conduct a background check on hospitalist job candidates, first and foremost to ensure patient safety and a safe practice environment for other healthcare providers, Lary says. There also is the issue of liability.
Financial liability for the negative acts of employees, whether accidental or intentional, is an area of exposure for businesses, says Les Rosen, president and CEO of Employment Screening Resources, a consumer reporting agency and human resources consulting firm in Novato, Calif. Businesses can be held liable for injuries resulting from the failure to adequately screen the people it hires. Background checks demonstrate the organization has done its due diligence in assessing the safety and competence of job candidates.
“It enables an organization to hire based upon facts, not just instincts,” Rosen says.
Background Basics
Hospitalists must be prepared to effectively deal with background checks throughout their professional careers. Employment checks often involve three areas: credentials verification, reference checking, and an additional background investigation.
Credentialing includes a review of the hospitalist’s completed education, training, residency, licenses, and any certifications, and often encompasses the candidate’s hospital privileges history, malpractice claims history, and peer reviews.
Reference checking involves verifying dates of employment and title at the hospitalist’s previous jobs, and contacting references to speak with them about the candidate’s qualifications.
Background investigations often are done by a third-party agency. The investigation will vary depending on the policies of the healthcare organization contracting the review, but, generally speaking, it includes a check of the following:
- Criminal and civil court records for criminal convictions, arrests, and lawsuits;
- Motor vehicle records and driver record status;
- The National Practitioner Data Bank for malpractice cases and medical board sanctions;
- Medicare sanction list of the Office of Inspector General in the U.S. Department of Health and Human Services;
- Social Security number; and
- Sex offender and terrorist databases.
Some investigations will include credit checks, which can cover credit payment history, bankruptcies, tax liens, and accounts placed into collections.
It is illegal during a background check to search for information related to a job candidate’s race, age, religion, sexual orientation, or any other protected category under the federal Civil Rights Act, says Cheryl Slack, vice president of human resources at Brentwood, Tenn.-based Cogent Healthcare.
Under the federal Fair Credit Reporting Act (www.ftc.gov/os/statutes/031224fcra.pdf), it also is illegal for a third-party consumer-reporting agency to perform an employment background check in secret, Rosen says. The applicant must authorize the check by signing a standalone disclosure form, he says. For the rare healthcare organizations that do their background checks in-house, most will seek consent.
Disclosure Is Crucial
Hospitalist job candidates should do whatever they can to make sure the people in charge of hiring aren’t surprised by what turns up in a background check, the experts say. “Nothing is more frustrating than finding out there is a problem late in the application process,” Lary says.
Hospitalists should inform the references they list on their resumes that they could be contacted. Such a “heads up” often gives a reference time to organize their thoughts about the job applicant and provide the best possible recommendation.
“You would be shocked at how many references are surprised to learn the hospitalist is looking for a job or how many applicants give as references people who don’t like them personally or professionally,” Lary says. “There are even times when physicians will take a pass on a reference. That speaks volumes.”
The most important thing a candidate should know is if there is something negative in their background that could be professionally damaging if discovered. It is best to make the people hiring aware of the information, Rosen says.
“Disclosure is best 100% of the time,” says Reuben Tovar, MD, chairman of Hospital Internists of Austin, a physician-owned and -managed hospitalist practice in Texas. “To deny or not include something on a resume or in an interview makes it look like you are a liar, or haven’t come to terms with what happened.”
The main impediment to disclosure is embarrassment and shame, says Dr. Tovar, who has encountered a number of physician candidates who have had problems. Those who disclose past issues are in a much better position to explain the situation and show how they have cleaned up a messy situation.
“Physicians are generally willing to at least consider giving their colleagues a second chance in employment and [hospital] credentialing if they are forthright,” Dr. Tovar says. “Not being forthright is an automatic exclusion.” TH
Lisa Ryan is a freelance writer based in New Jersey.
If the hospitalist recruitment process is a puzzle, then the background check is the vacuum cleaner, sweeping the area for any missing puzzle pieces.
“You are trying to get the whole picture,” Tim Lary, vice president of physician staffing at North Hollywood, Calif.-based IPC: The Hospitalist Company, says. “You are trying to see if something doesn’t fit right.”
Any competent healthcare organization will conduct a background check on hospitalist job candidates, first and foremost to ensure patient safety and a safe practice environment for other healthcare providers, Lary says. There also is the issue of liability.
Financial liability for the negative acts of employees, whether accidental or intentional, is an area of exposure for businesses, says Les Rosen, president and CEO of Employment Screening Resources, a consumer reporting agency and human resources consulting firm in Novato, Calif. Businesses can be held liable for injuries resulting from the failure to adequately screen the people it hires. Background checks demonstrate the organization has done its due diligence in assessing the safety and competence of job candidates.
“It enables an organization to hire based upon facts, not just instincts,” Rosen says.
Background Basics
Hospitalists must be prepared to effectively deal with background checks throughout their professional careers. Employment checks often involve three areas: credentials verification, reference checking, and an additional background investigation.
Credentialing includes a review of the hospitalist’s completed education, training, residency, licenses, and any certifications, and often encompasses the candidate’s hospital privileges history, malpractice claims history, and peer reviews.
Reference checking involves verifying dates of employment and title at the hospitalist’s previous jobs, and contacting references to speak with them about the candidate’s qualifications.
Background investigations often are done by a third-party agency. The investigation will vary depending on the policies of the healthcare organization contracting the review, but, generally speaking, it includes a check of the following:
- Criminal and civil court records for criminal convictions, arrests, and lawsuits;
- Motor vehicle records and driver record status;
- The National Practitioner Data Bank for malpractice cases and medical board sanctions;
- Medicare sanction list of the Office of Inspector General in the U.S. Department of Health and Human Services;
- Social Security number; and
- Sex offender and terrorist databases.
Some investigations will include credit checks, which can cover credit payment history, bankruptcies, tax liens, and accounts placed into collections.
It is illegal during a background check to search for information related to a job candidate’s race, age, religion, sexual orientation, or any other protected category under the federal Civil Rights Act, says Cheryl Slack, vice president of human resources at Brentwood, Tenn.-based Cogent Healthcare.
Under the federal Fair Credit Reporting Act (www.ftc.gov/os/statutes/031224fcra.pdf), it also is illegal for a third-party consumer-reporting agency to perform an employment background check in secret, Rosen says. The applicant must authorize the check by signing a standalone disclosure form, he says. For the rare healthcare organizations that do their background checks in-house, most will seek consent.
Disclosure Is Crucial
Hospitalist job candidates should do whatever they can to make sure the people in charge of hiring aren’t surprised by what turns up in a background check, the experts say. “Nothing is more frustrating than finding out there is a problem late in the application process,” Lary says.
Hospitalists should inform the references they list on their resumes that they could be contacted. Such a “heads up” often gives a reference time to organize their thoughts about the job applicant and provide the best possible recommendation.
“You would be shocked at how many references are surprised to learn the hospitalist is looking for a job or how many applicants give as references people who don’t like them personally or professionally,” Lary says. “There are even times when physicians will take a pass on a reference. That speaks volumes.”
The most important thing a candidate should know is if there is something negative in their background that could be professionally damaging if discovered. It is best to make the people hiring aware of the information, Rosen says.
“Disclosure is best 100% of the time,” says Reuben Tovar, MD, chairman of Hospital Internists of Austin, a physician-owned and -managed hospitalist practice in Texas. “To deny or not include something on a resume or in an interview makes it look like you are a liar, or haven’t come to terms with what happened.”
The main impediment to disclosure is embarrassment and shame, says Dr. Tovar, who has encountered a number of physician candidates who have had problems. Those who disclose past issues are in a much better position to explain the situation and show how they have cleaned up a messy situation.
“Physicians are generally willing to at least consider giving their colleagues a second chance in employment and [hospital] credentialing if they are forthright,” Dr. Tovar says. “Not being forthright is an automatic exclusion.” TH
Lisa Ryan is a freelance writer based in New Jersey.
Concurrent Care
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Decisions, Decisions
When Weijen William Chang, MD, entered college, he pursued a path he believed would allow him to do the most public good: He majored in journalism.
Before long, he was frustrated.
“I’d gather all of this information and disseminate it and realize the general public could take that information and do something with it, or maybe it wouldn’t,” Dr. Chang says.
Inspired by his father—a family medicine practitioner in Bakersfield, Calif.—he began to consider becoming a physician. Upon graduating from Johns Hopkins University in Baltimore, he opted for medical school over journalism, and later matched to Duke University’s combined medicine-pediatrics residency program.
“On the plus side, I knew what I was getting into,” says Dr. Chang, an adult hospitalist at the University of California at San Diego Medical Center and pediatric hospitalist across town at Rady Children’s Hospital. “Having watched my father, I knew how difficult medicine was as a lifestyle. Beyond that, I felt by pursuing medicine, I was able not only to acquire information, but also to use it in an effective way for the benefit of at least a small portion of the public.”
Question: What lesson did you learn from your father that made you a better physician?
Answer: His idea that a physician’s priority is the patient sitting in front of him or her. He has a very single-minded emphasis on doing everything a patient needs—and advocating for that patient’s needs—regardless of their ability to pay. He’s one of those people who will drive to the hospital in the middle of the night to see a patient in the emergency room. That devotion really set an example for me.
Q: How did he influence your career path?
A: I really wanted to model myself after my father to some extent. I wanted to be able to treat people of all ages like he does. The things he did were mostly general medicine and pediatrics. That’s what drove me into that residency program. I think both fields complement each other very well.
Q: What led you into HM?
A: I worked in a community health center in a Boston suburb for many years after residency. I found I had the ability to change the health of my patients, but in terms of effectively changing the health of a large number of people, it’s a lot more difficult than it sounds when you interface with community leaders. It required a lot more politics than I preferred to undertake.
Also, the pace of it is not really my style. I think HM is the perfect blend. It’s a fast-paced environment in which I get to see the fruits of my labor almost immediately. From a quality-improvement standpoint, it allows you to directly change the health of the population going into your hospital, which can be a fairly large population.
Q: Do you take a different approach when you’re treating children than when you’re caring for adult patients?
A: You definitely have to have a different approach. In adult medicine, we take a much broader picture of things. In pediatrics, there is a much higher attention to the very fine details of a patient’s case. Very small changes can result in drastic differences in patient outcomes.
Q: How does that affect the physician?
A: On a very basic level, there is a much higher level of anxiety about your decisions. Every decision you make in medicine is important, but the decisions are more important in pediatrics in some ways, because any mistake you might make is multiplied by many more decades of someone’s life. I think that anxiety probably is appropriate. The population is so fragile, and there’s much more to be lost if things go wrong.
Q: Why don’t more physicians do both?
A: A lot of med-peds residents feel like it’s impossible to do both. Once they come to the conclusion they want to become a hospitalist, they almost feel forced to go one way or another. Certainly, it is more difficult to be a hospitalist in both fields, but on some levels I think it’s more rewarding to do both. You’re able to see the best of both fields and cross-pollinate two departments in terms of practices and QI efforts.
Q: You have an impressive list of QI projects and major committee assignments. What motivates you to be so involved in those aspects of your programs?
A: I think most hospitalists are interested in fixing processes that are not working so well. I have a friend who is a nonmedical person who once told me, “Oh, you’re a hospitalist. Does that mean you fix hospitals?” He was joking, but in some ways, we’re not just treating patients, we’re treating the systems that support those patients. Treating the individual patient remains the highest priority. But improving the system we’re in is, if not as important, at least the next most important thing to make sure we do the best job we can.
Q: You practiced at Massachusetts General Hospital for seven years, and you ran the Boston Marathon while you were there. How did that come about?
A: The chief of HM had developed a fellowship in international refugee medicine called the Durant Fellowship, and they were begging for any person to join the marathon team so they could raise money. I figured, it’s now or never, so I said, “Heck, I’ll do it.”
Q: Are you glad you did?
A: It probably was one of the most memorable and inspiring things I’ve ever done. All of the charity runners run together. Many of them are cancer survivors. When you see them running next to you, and you know they finished their chemotherapy treatments just a couple months ago, it pushes you to finish. It inspires you to see how much determination they have.
Q: You also took part in a two-week medical mission to Honduras. What was that like?
A: It was a great experience, not just medically, but personally. It was eye-opening to see the general conditions that large portions of Hondurans live in and how basic their needs are.
Q: Did it change your professional perspective?
A: It makes you realize how lucky we are in the U.S. in terms of our healthcare system, and it makes you realize how fragile in general civilization is. It gives you some perspective into just how basic the needs are of many people and how important it is to try to contribute any time you might have to volunteer work.
Q: What’s next for you professionally?
A: Probably continuing to do what I do right now. When you’re in an academic institution, sometimes you feel like a small cog in a giant machine. That can sometimes make you feel small. In other ways, it is liberating, because you don’t necessarily have to deal with all the administrative problems you have to deal with in a smaller program. That frees me up to do QI projects I’m interested in. TH
Mark Leiser is a freelance writer based in New Jersey.
When Weijen William Chang, MD, entered college, he pursued a path he believed would allow him to do the most public good: He majored in journalism.
Before long, he was frustrated.
“I’d gather all of this information and disseminate it and realize the general public could take that information and do something with it, or maybe it wouldn’t,” Dr. Chang says.
Inspired by his father—a family medicine practitioner in Bakersfield, Calif.—he began to consider becoming a physician. Upon graduating from Johns Hopkins University in Baltimore, he opted for medical school over journalism, and later matched to Duke University’s combined medicine-pediatrics residency program.
“On the plus side, I knew what I was getting into,” says Dr. Chang, an adult hospitalist at the University of California at San Diego Medical Center and pediatric hospitalist across town at Rady Children’s Hospital. “Having watched my father, I knew how difficult medicine was as a lifestyle. Beyond that, I felt by pursuing medicine, I was able not only to acquire information, but also to use it in an effective way for the benefit of at least a small portion of the public.”
Question: What lesson did you learn from your father that made you a better physician?
Answer: His idea that a physician’s priority is the patient sitting in front of him or her. He has a very single-minded emphasis on doing everything a patient needs—and advocating for that patient’s needs—regardless of their ability to pay. He’s one of those people who will drive to the hospital in the middle of the night to see a patient in the emergency room. That devotion really set an example for me.
Q: How did he influence your career path?
A: I really wanted to model myself after my father to some extent. I wanted to be able to treat people of all ages like he does. The things he did were mostly general medicine and pediatrics. That’s what drove me into that residency program. I think both fields complement each other very well.
Q: What led you into HM?
A: I worked in a community health center in a Boston suburb for many years after residency. I found I had the ability to change the health of my patients, but in terms of effectively changing the health of a large number of people, it’s a lot more difficult than it sounds when you interface with community leaders. It required a lot more politics than I preferred to undertake.
Also, the pace of it is not really my style. I think HM is the perfect blend. It’s a fast-paced environment in which I get to see the fruits of my labor almost immediately. From a quality-improvement standpoint, it allows you to directly change the health of the population going into your hospital, which can be a fairly large population.
Q: Do you take a different approach when you’re treating children than when you’re caring for adult patients?
A: You definitely have to have a different approach. In adult medicine, we take a much broader picture of things. In pediatrics, there is a much higher attention to the very fine details of a patient’s case. Very small changes can result in drastic differences in patient outcomes.
Q: How does that affect the physician?
A: On a very basic level, there is a much higher level of anxiety about your decisions. Every decision you make in medicine is important, but the decisions are more important in pediatrics in some ways, because any mistake you might make is multiplied by many more decades of someone’s life. I think that anxiety probably is appropriate. The population is so fragile, and there’s much more to be lost if things go wrong.
Q: Why don’t more physicians do both?
A: A lot of med-peds residents feel like it’s impossible to do both. Once they come to the conclusion they want to become a hospitalist, they almost feel forced to go one way or another. Certainly, it is more difficult to be a hospitalist in both fields, but on some levels I think it’s more rewarding to do both. You’re able to see the best of both fields and cross-pollinate two departments in terms of practices and QI efforts.
Q: You have an impressive list of QI projects and major committee assignments. What motivates you to be so involved in those aspects of your programs?
A: I think most hospitalists are interested in fixing processes that are not working so well. I have a friend who is a nonmedical person who once told me, “Oh, you’re a hospitalist. Does that mean you fix hospitals?” He was joking, but in some ways, we’re not just treating patients, we’re treating the systems that support those patients. Treating the individual patient remains the highest priority. But improving the system we’re in is, if not as important, at least the next most important thing to make sure we do the best job we can.
Q: You practiced at Massachusetts General Hospital for seven years, and you ran the Boston Marathon while you were there. How did that come about?
A: The chief of HM had developed a fellowship in international refugee medicine called the Durant Fellowship, and they were begging for any person to join the marathon team so they could raise money. I figured, it’s now or never, so I said, “Heck, I’ll do it.”
Q: Are you glad you did?
A: It probably was one of the most memorable and inspiring things I’ve ever done. All of the charity runners run together. Many of them are cancer survivors. When you see them running next to you, and you know they finished their chemotherapy treatments just a couple months ago, it pushes you to finish. It inspires you to see how much determination they have.
Q: You also took part in a two-week medical mission to Honduras. What was that like?
A: It was a great experience, not just medically, but personally. It was eye-opening to see the general conditions that large portions of Hondurans live in and how basic their needs are.
Q: Did it change your professional perspective?
A: It makes you realize how lucky we are in the U.S. in terms of our healthcare system, and it makes you realize how fragile in general civilization is. It gives you some perspective into just how basic the needs are of many people and how important it is to try to contribute any time you might have to volunteer work.
Q: What’s next for you professionally?
A: Probably continuing to do what I do right now. When you’re in an academic institution, sometimes you feel like a small cog in a giant machine. That can sometimes make you feel small. In other ways, it is liberating, because you don’t necessarily have to deal with all the administrative problems you have to deal with in a smaller program. That frees me up to do QI projects I’m interested in. TH
Mark Leiser is a freelance writer based in New Jersey.
When Weijen William Chang, MD, entered college, he pursued a path he believed would allow him to do the most public good: He majored in journalism.
Before long, he was frustrated.
“I’d gather all of this information and disseminate it and realize the general public could take that information and do something with it, or maybe it wouldn’t,” Dr. Chang says.
Inspired by his father—a family medicine practitioner in Bakersfield, Calif.—he began to consider becoming a physician. Upon graduating from Johns Hopkins University in Baltimore, he opted for medical school over journalism, and later matched to Duke University’s combined medicine-pediatrics residency program.
“On the plus side, I knew what I was getting into,” says Dr. Chang, an adult hospitalist at the University of California at San Diego Medical Center and pediatric hospitalist across town at Rady Children’s Hospital. “Having watched my father, I knew how difficult medicine was as a lifestyle. Beyond that, I felt by pursuing medicine, I was able not only to acquire information, but also to use it in an effective way for the benefit of at least a small portion of the public.”
Question: What lesson did you learn from your father that made you a better physician?
Answer: His idea that a physician’s priority is the patient sitting in front of him or her. He has a very single-minded emphasis on doing everything a patient needs—and advocating for that patient’s needs—regardless of their ability to pay. He’s one of those people who will drive to the hospital in the middle of the night to see a patient in the emergency room. That devotion really set an example for me.
Q: How did he influence your career path?
A: I really wanted to model myself after my father to some extent. I wanted to be able to treat people of all ages like he does. The things he did were mostly general medicine and pediatrics. That’s what drove me into that residency program. I think both fields complement each other very well.
Q: What led you into HM?
A: I worked in a community health center in a Boston suburb for many years after residency. I found I had the ability to change the health of my patients, but in terms of effectively changing the health of a large number of people, it’s a lot more difficult than it sounds when you interface with community leaders. It required a lot more politics than I preferred to undertake.
Also, the pace of it is not really my style. I think HM is the perfect blend. It’s a fast-paced environment in which I get to see the fruits of my labor almost immediately. From a quality-improvement standpoint, it allows you to directly change the health of the population going into your hospital, which can be a fairly large population.
Q: Do you take a different approach when you’re treating children than when you’re caring for adult patients?
A: You definitely have to have a different approach. In adult medicine, we take a much broader picture of things. In pediatrics, there is a much higher attention to the very fine details of a patient’s case. Very small changes can result in drastic differences in patient outcomes.
Q: How does that affect the physician?
A: On a very basic level, there is a much higher level of anxiety about your decisions. Every decision you make in medicine is important, but the decisions are more important in pediatrics in some ways, because any mistake you might make is multiplied by many more decades of someone’s life. I think that anxiety probably is appropriate. The population is so fragile, and there’s much more to be lost if things go wrong.
Q: Why don’t more physicians do both?
A: A lot of med-peds residents feel like it’s impossible to do both. Once they come to the conclusion they want to become a hospitalist, they almost feel forced to go one way or another. Certainly, it is more difficult to be a hospitalist in both fields, but on some levels I think it’s more rewarding to do both. You’re able to see the best of both fields and cross-pollinate two departments in terms of practices and QI efforts.
Q: You have an impressive list of QI projects and major committee assignments. What motivates you to be so involved in those aspects of your programs?
A: I think most hospitalists are interested in fixing processes that are not working so well. I have a friend who is a nonmedical person who once told me, “Oh, you’re a hospitalist. Does that mean you fix hospitals?” He was joking, but in some ways, we’re not just treating patients, we’re treating the systems that support those patients. Treating the individual patient remains the highest priority. But improving the system we’re in is, if not as important, at least the next most important thing to make sure we do the best job we can.
Q: You practiced at Massachusetts General Hospital for seven years, and you ran the Boston Marathon while you were there. How did that come about?
A: The chief of HM had developed a fellowship in international refugee medicine called the Durant Fellowship, and they were begging for any person to join the marathon team so they could raise money. I figured, it’s now or never, so I said, “Heck, I’ll do it.”
Q: Are you glad you did?
A: It probably was one of the most memorable and inspiring things I’ve ever done. All of the charity runners run together. Many of them are cancer survivors. When you see them running next to you, and you know they finished their chemotherapy treatments just a couple months ago, it pushes you to finish. It inspires you to see how much determination they have.
Q: You also took part in a two-week medical mission to Honduras. What was that like?
A: It was a great experience, not just medically, but personally. It was eye-opening to see the general conditions that large portions of Hondurans live in and how basic their needs are.
Q: Did it change your professional perspective?
A: It makes you realize how lucky we are in the U.S. in terms of our healthcare system, and it makes you realize how fragile in general civilization is. It gives you some perspective into just how basic the needs are of many people and how important it is to try to contribute any time you might have to volunteer work.
Q: What’s next for you professionally?
A: Probably continuing to do what I do right now. When you’re in an academic institution, sometimes you feel like a small cog in a giant machine. That can sometimes make you feel small. In other ways, it is liberating, because you don’t necessarily have to deal with all the administrative problems you have to deal with in a smaller program. That frees me up to do QI projects I’m interested in. TH
Mark Leiser is a freelance writer based in New Jersey.