Recent studies, published in mass media and professional publications alike, warn of a physician shortage expected to worsen progressively during the next 15 years and to peak around 2020. The predicted scope of the national deficit ranges from 85,000 to 200,000 physicians. Analyses of the causes of the shortage conclude that the rate of population growth will exceed growth in the number of physicians, while demand for physician services continues to expand. The projected shortage of physicians is likely to have the greatest effect on underserved and poorer communities that have historically had the most difficulty recruiting and retaining physicians.

In response, hospitals are implementing, expanding, or refining recruitment and retention programs. Practices are increasingly offering part-time work, flex-time, and job-sharing arrangements. In addition to flexible schedules, physician recruitment packages may include sign-on bonuses, relocation allowances, student loan repayment, income guarantees, favorable loans, and other incentives. Additional incentives are available to physicians willing to practice in federally recognized Health Professional Shortage Areas (HPSA) and to those who practice in specialties governed by HPSA regulations, such as family practice, internal medicine, pediatrics, obstetrics and gynecology, oral surgery, mental health, vision care, and podiatry.

These recruiting arrangements are governed by a variety of laws and regulations. Because of the infinite number of factors affecting any given recruitment arrangement, a comprehensive discussion of all the legal implications in recruitment arrangements is beyond the scope of this article. We will, however, provide an overview of three key legal concepts that physicians should consider when evaluating a hospital’s recruiting package. We’ll address recruiting packages offered by medical practices in a later article.

Stark Law

Unless an express exception applies, federal legislation prohibits physicians from making referrals for “designated health services” to entities with which the physician (or an immediate family member) has a “financial relationship.” The law also prohibits entities from submitting claims for services provided in the course of making a prohibited referral.

The Stark legislation broadly defines “financial relationships” as including direct ownership, indirect ownership, investment interests, and compensation arrangements. Similarly, the law broadly defines “designated health services” to include clinical laboratory, physical therapy, occupational therapy, speech pathology, radiology, radiation therapy, home health, and inpatient and outpatient hospital services. “Designated health services” are not limited purely to services rendered and include the provision of radiation therapy supplies, durable medical equipment and supplies, certain nutrients, prosthetics, orthotics, and prescription drugs. A classic example of an arrangement that would violate the Stark legislation is an orthopedic surgeon who refers patients to a physical therapy facility in which he owns a controlling interest.

In general, physicians should be wary of any relationship that involves referring patients to entities in which they have any financial interest, but there are a number of exceptions within the Stark legislation. The Stark law is a strict liability statute; thus, unless an express exception applies, a violation of the statute subjects the provider and entity to liability. For this article, we are concerned with only one of the exceptions, which applies when hospitals and Federally Qualified Health Centers recruit physicians to their geographic service areas.

Specifically, these entities may offer remuneration to induce physicians to relocate and join the medical staff as long as the recruited physicians are not required to refer patients to the facility and provided that the amount of any physician remuneration does not take into account the volume or value of patient referrals. In other words, although the hospital may recruit a physician, it cannot use the recruiting contract to require the physician to make a certain number of referrals or generate a certain amount of revenue.

It is also important to note that the recruiting exception is designed to promote true recruiting, not simply to entice an established physician in the community to move her practice to a competing hospital. Consequently, the recruiting exception does not apply unless the recruited physician will either move her practice at least 25 miles or generate 75% of her revenues from new patients.

Anti-Kickback Statute

The anti-kickback statute prohibits healthcare providers or entities from knowingly offering or accepting remuneration to induce or reward referrals. Federal regulations create “safe harbors” outlining criteria that, if met, shield providers and entities from anti-kickback liability. The recruitment safe harbor requires a recruited physician leaving an existing medical practice to relocate at least 100 miles away and to generate 85% of new practice revenues from patients not seen at the former practice. Further, the recruited physician must agree to treat Medicare and Medicaid patients.

Internal Revenue Code

Any tax-exempt entity and its physician recruits must carefully structure recruiting arrangements to avoid jeopardizing the entity’s tax-exempt status. Moreover, certain recruitment incentives have tax consequences for an individual recruit.

Tax-exempt entities: Generally, a tax-exempt entity’s earnings may not benefit private individuals. If an improper benefit is found, both the entity and the individual are subject to penalties, including the potential loss of the entity’s tax-exempt status. Thus, physician-recruiting payments by tax-exempt hospitals must fit within IRS requirements.

Specifically, when a tax-exempt hospital recruits a physician to provide service on behalf of the organization, the arrangement must meet an “operational test.” The operational test requires the hospital to account for all of the physician’s services and demonstrate that it is paying reasonable compensation. Consequently, when a tax-exempt hospital recruits a physician to provide services not just for the hospital but also for the surrounding community, it must ensure that all conduct is consistent with the facility’s tax-exempt purpose. Thus, for example, a tax-exempt hospital that has a charitable purpose may be able to justify a recruiting arrangement that allows a physician to provide services that promote the health of the surrounding community.

Ultimately, the IRS is responsible for determining that a tax-exempt hospital is not using its funds solely to promote the physician’s personal interests. Consequently, a tax-exempt hospital should be prepared to demonstrate the reasons the physician was recruited, the need the recruited physician fills, ways in which the recruitment furthers the hospital’s purpose, evidence that the recruiting agreement was negotiated in good faith, and proof that none of the participants in the negotiation suffered from a conflict of interest.

Tax consequences to recruits: Notably, recruiting packages may offer incentives to the recruit that the IRS may consider taxable income. For example, many recruiting arrangements include loans to guarantee a certain level of income and cover the costs associated with starting up a new practice or adding a physician to an existing practice. These loans may be forgiven over time if the recruited physician continues practicing in the community. Generally, proceeds of a loan do not constitute taxable income because the benefit is offset by an obligation to repay. When a loan is subject to forgiveness, however, the forgiven portion may be taxable. Consequently, recruits should evaluate any recruitment incentives in the context of their long-term tax consequences.

Conclusion

Federal law recognizes that communities benefit when hospitals recruit physicians to meet a particular need, but the law does not allow hospitals or physicians to abuse the recruiting relationship.

In evaluating a hospital’s recruiting agreement, physicians should ensure that the agreement does not require them to refer patients to a particular facility, does not calculate their remuneration based upon the number or value of referrals, meets the requirements of relocation or establishment of a new patient base, is consistent with the hospital’s tax status, and does not expose the physician to unintended tax liabilities. TH

O’Rourke works in the Office of University Counsel, Department of Litigation, Denver.

Recent studies, published in mass media and professional publications alike, warn of a physician shortage expected to worsen progressively during the next 15 years and to peak around 2020. The predicted scope of the national deficit ranges from 85,000 to 200,000 physicians. Analyses of the causes of the shortage conclude that the rate of population growth will exceed growth in the number of physicians, while demand for physician services continues to expand. The projected shortage of physicians is likely to have the greatest effect on underserved and poorer communities that have historically had the most difficulty recruiting and retaining physicians.

In response, hospitals are implementing, expanding, or refining recruitment and retention programs. Practices are increasingly offering part-time work, flex-time, and job-sharing arrangements. In addition to flexible schedules, physician recruitment packages may include sign-on bonuses, relocation allowances, student loan repayment, income guarantees, favorable loans, and other incentives. Additional incentives are available to physicians willing to practice in federally recognized Health Professional Shortage Areas (HPSA) and to those who practice in specialties governed by HPSA regulations, such as family practice, internal medicine, pediatrics, obstetrics and gynecology, oral surgery, mental health, vision care, and podiatry.

These recruiting arrangements are governed by a variety of laws and regulations. Because of the infinite number of factors affecting any given recruitment arrangement, a comprehensive discussion of all the legal implications in recruitment arrangements is beyond the scope of this article. We will, however, provide an overview of three key legal concepts that physicians should consider when evaluating a hospital’s recruiting package. We’ll address recruiting packages offered by medical practices in a later article.

Stark Law

Unless an express exception applies, federal legislation prohibits physicians from making referrals for “designated health services” to entities with which the physician (or an immediate family member) has a “financial relationship.” The law also prohibits entities from submitting claims for services provided in the course of making a prohibited referral.

The Stark legislation broadly defines “financial relationships” as including direct ownership, indirect ownership, investment interests, and compensation arrangements. Similarly, the law broadly defines “designated health services” to include clinical laboratory, physical therapy, occupational therapy, speech pathology, radiology, radiation therapy, home health, and inpatient and outpatient hospital services. “Designated health services” are not limited purely to services rendered and include the provision of radiation therapy supplies, durable medical equipment and supplies, certain nutrients, prosthetics, orthotics, and prescription drugs. A classic example of an arrangement that would violate the Stark legislation is an orthopedic surgeon who refers patients to a physical therapy facility in which he owns a controlling interest.

In general, physicians should be wary of any relationship that involves referring patients to entities in which they have any financial interest, but there are a number of exceptions within the Stark legislation. The Stark law is a strict liability statute; thus, unless an express exception applies, a violation of the statute subjects the provider and entity to liability. For this article, we are concerned with only one of the exceptions, which applies when hospitals and Federally Qualified Health Centers recruit physicians to their geographic service areas.

Specifically, these entities may offer remuneration to induce physicians to relocate and join the medical staff as long as the recruited physicians are not required to refer patients to the facility and provided that the amount of any physician remuneration does not take into account the volume or value of patient referrals. In other words, although the hospital may recruit a physician, it cannot use the recruiting contract to require the physician to make a certain number of referrals or generate a certain amount of revenue.

It is also important to note that the recruiting exception is designed to promote true recruiting, not simply to entice an established physician in the community to move her practice to a competing hospital. Consequently, the recruiting exception does not apply unless the recruited physician will either move her practice at least 25 miles or generate 75% of her revenues from new patients.

Anti-Kickback Statute

The anti-kickback statute prohibits healthcare providers or entities from knowingly offering or accepting remuneration to induce or reward referrals. Federal regulations create “safe harbors” outlining criteria that, if met, shield providers and entities from anti-kickback liability. The recruitment safe harbor requires a recruited physician leaving an existing medical practice to relocate at least 100 miles away and to generate 85% of new practice revenues from patients not seen at the former practice. Further, the recruited physician must agree to treat Medicare and Medicaid patients.

Internal Revenue Code

Any tax-exempt entity and its physician recruits must carefully structure recruiting arrangements to avoid jeopardizing the entity’s tax-exempt status. Moreover, certain recruitment incentives have tax consequences for an individual recruit.

Tax-exempt entities: Generally, a tax-exempt entity’s earnings may not benefit private individuals. If an improper benefit is found, both the entity and the individual are subject to penalties, including the potential loss of the entity’s tax-exempt status. Thus, physician-recruiting payments by tax-exempt hospitals must fit within IRS requirements.

Specifically, when a tax-exempt hospital recruits a physician to provide service on behalf of the organization, the arrangement must meet an “operational test.” The operational test requires the hospital to account for all of the physician’s services and demonstrate that it is paying reasonable compensation. Consequently, when a tax-exempt hospital recruits a physician to provide services not just for the hospital but also for the surrounding community, it must ensure that all conduct is consistent with the facility’s tax-exempt purpose. Thus, for example, a tax-exempt hospital that has a charitable purpose may be able to justify a recruiting arrangement that allows a physician to provide services that promote the health of the surrounding community.

Ultimately, the IRS is responsible for determining that a tax-exempt hospital is not using its funds solely to promote the physician’s personal interests. Consequently, a tax-exempt hospital should be prepared to demonstrate the reasons the physician was recruited, the need the recruited physician fills, ways in which the recruitment furthers the hospital’s purpose, evidence that the recruiting agreement was negotiated in good faith, and proof that none of the participants in the negotiation suffered from a conflict of interest.

Tax consequences to recruits: Notably, recruiting packages may offer incentives to the recruit that the IRS may consider taxable income. For example, many recruiting arrangements include loans to guarantee a certain level of income and cover the costs associated with starting up a new practice or adding a physician to an existing practice. These loans may be forgiven over time if the recruited physician continues practicing in the community. Generally, proceeds of a loan do not constitute taxable income because the benefit is offset by an obligation to repay. When a loan is subject to forgiveness, however, the forgiven portion may be taxable. Consequently, recruits should evaluate any recruitment incentives in the context of their long-term tax consequences.

Conclusion

Federal law recognizes that communities benefit when hospitals recruit physicians to meet a particular need, but the law does not allow hospitals or physicians to abuse the recruiting relationship.

In evaluating a hospital’s recruiting agreement, physicians should ensure that the agreement does not require them to refer patients to a particular facility, does not calculate their remuneration based upon the number or value of referrals, meets the requirements of relocation or establishment of a new patient base, is consistent with the hospital’s tax status, and does not expose the physician to unintended tax liabilities. TH

O’Rourke works in the Office of University Counsel, Department of Litigation, Denver.

Recent studies, published in mass media and professional publications alike, warn of a physician shortage expected to worsen progressively during the next 15 years and to peak around 2020. The predicted scope of the national deficit ranges from 85,000 to 200,000 physicians. Analyses of the causes of the shortage conclude that the rate of population growth will exceed growth in the number of physicians, while demand for physician services continues to expand. The projected shortage of physicians is likely to have the greatest effect on underserved and poorer communities that have historically had the most difficulty recruiting and retaining physicians.

In response, hospitals are implementing, expanding, or refining recruitment and retention programs. Practices are increasingly offering part-time work, flex-time, and job-sharing arrangements. In addition to flexible schedules, physician recruitment packages may include sign-on bonuses, relocation allowances, student loan repayment, income guarantees, favorable loans, and other incentives. Additional incentives are available to physicians willing to practice in federally recognized Health Professional Shortage Areas (HPSA) and to those who practice in specialties governed by HPSA regulations, such as family practice, internal medicine, pediatrics, obstetrics and gynecology, oral surgery, mental health, vision care, and podiatry.

These recruiting arrangements are governed by a variety of laws and regulations. Because of the infinite number of factors affecting any given recruitment arrangement, a comprehensive discussion of all the legal implications in recruitment arrangements is beyond the scope of this article. We will, however, provide an overview of three key legal concepts that physicians should consider when evaluating a hospital’s recruiting package. We’ll address recruiting packages offered by medical practices in a later article.

Stark Law

Unless an express exception applies, federal legislation prohibits physicians from making referrals for “designated health services” to entities with which the physician (or an immediate family member) has a “financial relationship.” The law also prohibits entities from submitting claims for services provided in the course of making a prohibited referral.

The Stark legislation broadly defines “financial relationships” as including direct ownership, indirect ownership, investment interests, and compensation arrangements. Similarly, the law broadly defines “designated health services” to include clinical laboratory, physical therapy, occupational therapy, speech pathology, radiology, radiation therapy, home health, and inpatient and outpatient hospital services. “Designated health services” are not limited purely to services rendered and include the provision of radiation therapy supplies, durable medical equipment and supplies, certain nutrients, prosthetics, orthotics, and prescription drugs. A classic example of an arrangement that would violate the Stark legislation is an orthopedic surgeon who refers patients to a physical therapy facility in which he owns a controlling interest.

In general, physicians should be wary of any relationship that involves referring patients to entities in which they have any financial interest, but there are a number of exceptions within the Stark legislation. The Stark law is a strict liability statute; thus, unless an express exception applies, a violation of the statute subjects the provider and entity to liability. For this article, we are concerned with only one of the exceptions, which applies when hospitals and Federally Qualified Health Centers recruit physicians to their geographic service areas.

Specifically, these entities may offer remuneration to induce physicians to relocate and join the medical staff as long as the recruited physicians are not required to refer patients to the facility and provided that the amount of any physician remuneration does not take into account the volume or value of patient referrals. In other words, although the hospital may recruit a physician, it cannot use the recruiting contract to require the physician to make a certain number of referrals or generate a certain amount of revenue.

It is also important to note that the recruiting exception is designed to promote true recruiting, not simply to entice an established physician in the community to move her practice to a competing hospital. Consequently, the recruiting exception does not apply unless the recruited physician will either move her practice at least 25 miles or generate 75% of her revenues from new patients.

Anti-Kickback Statute

The anti-kickback statute prohibits healthcare providers or entities from knowingly offering or accepting remuneration to induce or reward referrals. Federal regulations create “safe harbors” outlining criteria that, if met, shield providers and entities from anti-kickback liability. The recruitment safe harbor requires a recruited physician leaving an existing medical practice to relocate at least 100 miles away and to generate 85% of new practice revenues from patients not seen at the former practice. Further, the recruited physician must agree to treat Medicare and Medicaid patients.

Internal Revenue Code

Any tax-exempt entity and its physician recruits must carefully structure recruiting arrangements to avoid jeopardizing the entity’s tax-exempt status. Moreover, certain recruitment incentives have tax consequences for an individual recruit.

Tax-exempt entities: Generally, a tax-exempt entity’s earnings may not benefit private individuals. If an improper benefit is found, both the entity and the individual are subject to penalties, including the potential loss of the entity’s tax-exempt status. Thus, physician-recruiting payments by tax-exempt hospitals must fit within IRS requirements.

Specifically, when a tax-exempt hospital recruits a physician to provide service on behalf of the organization, the arrangement must meet an “operational test.” The operational test requires the hospital to account for all of the physician’s services and demonstrate that it is paying reasonable compensation. Consequently, when a tax-exempt hospital recruits a physician to provide services not just for the hospital but also for the surrounding community, it must ensure that all conduct is consistent with the facility’s tax-exempt purpose. Thus, for example, a tax-exempt hospital that has a charitable purpose may be able to justify a recruiting arrangement that allows a physician to provide services that promote the health of the surrounding community.

Ultimately, the IRS is responsible for determining that a tax-exempt hospital is not using its funds solely to promote the physician’s personal interests. Consequently, a tax-exempt hospital should be prepared to demonstrate the reasons the physician was recruited, the need the recruited physician fills, ways in which the recruitment furthers the hospital’s purpose, evidence that the recruiting agreement was negotiated in good faith, and proof that none of the participants in the negotiation suffered from a conflict of interest.

Tax consequences to recruits: Notably, recruiting packages may offer incentives to the recruit that the IRS may consider taxable income. For example, many recruiting arrangements include loans to guarantee a certain level of income and cover the costs associated with starting up a new practice or adding a physician to an existing practice. These loans may be forgiven over time if the recruited physician continues practicing in the community. Generally, proceeds of a loan do not constitute taxable income because the benefit is offset by an obligation to repay. When a loan is subject to forgiveness, however, the forgiven portion may be taxable. Consequently, recruits should evaluate any recruitment incentives in the context of their long-term tax consequences.

Conclusion

Federal law recognizes that communities benefit when hospitals recruit physicians to meet a particular need, but the law does not allow hospitals or physicians to abuse the recruiting relationship.

In evaluating a hospital’s recruiting agreement, physicians should ensure that the agreement does not require them to refer patients to a particular facility, does not calculate their remuneration based upon the number or value of referrals, meets the requirements of relocation or establishment of a new patient base, is consistent with the hospital’s tax status, and does not expose the physician to unintended tax liabilities. TH

O’Rourke works in the Office of University Counsel, Department of Litigation, Denver.

A58-year-old white female presented with an eight-month history of progressive lower abdominal pain and bloating. She experienced intermittent constipation followed by a five-month period of persistent loose, watery diarrhea, a 35-pound weight loss, fatigue, anorexia, and avoidance of food.

Her past medical and surgical history were significant for hypertension, depression, appendectomy, laparoscopic ovarian cystectomy (of benign histology), and cholelithiasis. Her medication list consisted of pindolol and sertraline. Her physical exam was remarkable for abdominal distention, palpable mass, fluid wave, shifting dullness, and hypoactive bowel sounds. There was no tenderness or organomegaly. She had a mild microcytic anemia with no leukocytosis. Liver chemistries and electrolytes were normal. The erythrocyte sedimentation rate was 51. The initial CT scan of the abdomen is shown at right. TH

What is the most likely differential diagnosis?

1. Pneumatosis intestinalis;
2. Ovarian carcinoma or peritoneal carcinomatosis;
3. Sclerosing mesenteritis;
4. Spontaneous bacterial peritonitis; or
5. Lymphoma.

Discussion

The answer is C: sclerosing mesenteritis (SM). The CT scan shows a bulky heterogeneous mesenteric mass measuring approximately 8.7 x 6 x 10 cm, with a focal, 2-cm calcification at the lateral margin. The mass began at the proximal superior mesenteric artery, extended inferiorly to the top of the pelvis, and encased the body of the pancreas, central mesenteric vessels and the confluence of the portal, splenic, and superior mesenteric veins (SMV). The SMV was poorly visualized and may have been compressed or occluded by the mass. Diffuse abdominal and pelvic ascites also were seen.

Results of a needle biopsy of the mesenteric mass showed fibrous tissue and a mixed population of B cells and T cells consistent with sclerosing mesenteritis, a fibroinflammatory reactive process.

Sclerosing or retractile mesenteritis is an uncommon, idiopathic, nonneoplastic, tumor-like lesion that thickens and shortens the mesentery.1 The condition consists of a pathophysiological spectrum of disease, the classification of which is based on the predominant histological finding on tissue biopsy. Cases in which the predominant findings are fatty degeneration and necrosis are known as the mesenteric lipodystrophy variant; those in which chronic inflammation predominates are known as the mesenteric panniculitis variant; and finally, the predominantly fibrotic form is known as the retractile mesenteritis or mesenteric fibrosis variant.

The presence of some degree of fibrosis, chronic inflammation, and fat necrosis in all three lesions, as well as their common demographic and clinical characteristics, suggest that the three diagnostic groups represent a single clinical entity.2 Sclerosing mesenteritis is used as an umbrella term that encompasses all three histologic variants.

Numerous theories exist to explain the pathogenesis of the condition, most commonly relating to a non-specific reaction to mesenteric injuries such as antecedent surgery or abdominal trauma, or possibly autoimmunity, ischemia/infection, and or paraneoplastic phenomena.

A study of 68 cases of mesenteric panniculitis undertaken by Durst, et al., showed that the age range is diverse, affecting patients from seven to 82 years.3 In another study, Emory, et al., reported an average age of 60.1 years at presentation.2 In both studies there was a slight male preponderance, with a male: female ratio of 1.9:1, and 1.8:1.2,3

In the largest reported experience with patients with sclerosing mesenteritis from a single institution, the majority were male (72%) with an age range of 34-87 years.10,11 Of these patients, the most common presenting complaints are abdominal pain (36%-67%), vomiting (18%-32%), palpable abdominal mass (16%), anorexia (7%-17%), weight loss (14%-45%), constipation (8%-15%), diarrhea (7%-26%), and rectal bleeding (5%). The duration of symptoms varies from 24 hours to two years.3-10 In most cases, the blood chemistry and urinalysis were reported to be normal, although an elevated sedimentation rate has been reported in a minority.3,11

Diagnosis usually depends on imaging studies (most often CT scan) and pathological review of biopsy specimens. Concurrent pathology is found in 18%-25% of cases, including lymphoma (7%), cholelithiasis (4%), cirrhosis of the liver (3%), and abdominal aortic aneurysm (3%).3,10 Other conditions associated with idiopathic fibrosis, such as retroperitoneal fibrosis and sclerosing pancreatitis, have been reported to occur together with SM.4,10

To date, treatment options are guided by anecdotal experience and reports of open label clinical results.10,11 Clinical and experimental studies have suggested a possible hormonal influence on fibrous proliferation in retroperitoneal fibrosis, which led to the discovery of the beneficial effect of anti-estrogenic treatment with tamoxifen.5,6 Clark, et al., had noticed that tamoxifen was successfully used in the treatment of desmoid tumors and then reported its use in two cases of retroperitoneal fibrosis.5 Others have since used tamoxifen in sclerosing mesenteritis, including a relatively large experience from our institution that suggests the combination of tamoxifen with a prednisone taper may be the most beneficial treatment for this condition.7,10,11

Other treatments that have been reported to be of some benefit include combination of corticosteroids and colchicine or azathioprine, although these reports include very small numbers of patients.8,10 Ginsburg, et al., reported their experience with thalidomide in a short term, open-label study in five symptomatic subjects.12 Four patients (80%) experienced an improvement in symptoms, and one achieved complete remission by week four, which was sustained. There was also a decrease in inflammatory markers, although no changes were noted on follow-up CT scans.

The natural history of sclerosing mesenteritis is quite variable, with a few patients undergoing spontaneous remission, many experiencing an indolent course, and others progressing to bowel obstruction or other complications, including chylous ascites, mesenteric venous or arterial occlusion, and malnutrition (often resulting in the need for parenteral nutrition).10,11 There have been fatal cases of this condition reported in the literature; however, Durst, et al., found that of 40 patients undergoing exploratory laparotomy and biopsy, only one patient died as a direct result of the disease after 12 years and several explorations.9-11 In the remaining 39 patients, their symptoms resolved without any further treatment, although in some the abdominal mass was persistently palpable.3. Similarly Emory, et al., found that after following 42 patients for an average of 9.5 years, only three patients had complications that resulted in death, all of which occurred in the postoperative period.2

In our experience, three of 92 patients (3%) died from causes that were thought to be attributable to sclerosing mesenteritis or its treatment.10,11

In summary, sclerosing mesenteritis is a rare disease entity that thickens and shortens the mesentery due to a non-specific fibroinflammatory reaction in the mesentery. Diagnosis relies on CT scanning and tissue biopsy, which shows variable degrees of fibrosis, chronic inflammation, and fat necrosis. Treatment options are based on anecdotal experience only. Tamoxifen, with or without combination therapy with prednisone, colchicine, azathioprine, and thalidomide, appears to be of some benefit. Prognosis is variable, with some patients achieving remission while others die from complications related to disease progression such as bowel obstruction, mesenteric vascular occlusion, and malnutrition; however, many have persistent symptoms that may improve but not resolve with medical therapy. TH

References

1. Kelly JK, Hwang WS. Idiopathic retractile (sclerosing) mesenteritis and its differential diagnosis. Am J Surg Pathol. 1989;13(6):513-521.
2. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol. 1997 Apr;21(4):392.
3. Durst AL, Freund H, Rosenmann E, et al. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery. 1977;81:203.
4. Chew CK, Jarzylo SV, Valberg LS. Idiopathic retroperitoneal fibrosis with protein-losing enteropathy and duodenal obstruction successfully treated with corticosteroids. Can Med Assoc J. 1966;95(23):1183-1188.
5. Clark CP, Vanderpool D, Preskitt JT. The response of retroperitoneal fibrosis to tamoxifen. Surgery. 1991 Apr;109(4):502-506.
6. Owens LV, Cance WG, Huth JF. Retroperitoneal fibrosis treated with tamoxifen. Am Surg. 1995;61:842-844.
7. Venkataramani A, Behling CA, Lynche KD. Sclerosing mesenteritis: an unusual cause of abdominal pain in an HIV-positive patient. Am J Gastroenterol. 1997 Jun;92(6):1059-1060.
8. Genereau T, Bellin MF, Wechsler B. Demonstration of efficacy of combining corticosteroids and colchicine in two patients with idiopathic sclerosing mesenteritis. Dig Dis Sci. 1996;41(4):684-688.
9. Andersen JA, Rasmussen NR, Pedersen JK. Mesenteric panniculitis: a fatal case. Am J Gastroenterol. 1982 Jul;77(7):523-525.
10. Akram S, Pardi DS, Smyrk TC. Sclerosing mesenteritis: The Mayo Clinic Experience. (Clinical features and tx response) Gastroenterology. 2003;A-190.
11. Akram S, Pardi DS, Smyrk TC. Effect of tamoxifen on clinical course of sclerosing mesenteritis. Gastroenterology. 2006;130:A-322.
12. Ginsburg PM, Ehrenpreis ED. A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis. Aliment Pharmacol Ther. 2002 Dec;16(12):2115-2122.

Historic Puzzler #3: The Root of the Problem

In 1777 G.F. was traveling through the South Pacific Islands as a naturalist. He witnessed a ceremony that involved a substance being “ … made in the most disgustful [sic] manner that can be imagined, from the roots of a species of pepper-tree. The root is cut small and the pieces chewed by several people, who spit the macerated mass into a bowl. … They strain it through a quantity of fibers … and mix with the coconut milk. They swallow this nauseous stuff as fast as possible; and some old topes value themselves on being able to empty a great number of bowls.”

Who was GF, the captain of this expedition, and what was the root?

Recent reports suggest possible hepatotoxicity from this substance. For extra credit, what are the dermatologic and neuro-ophthalmologic side effects of chronic heavy ingestion?

A58-year-old white female presented with an eight-month history of progressive lower abdominal pain and bloating. She experienced intermittent constipation followed by a five-month period of persistent loose, watery diarrhea, a 35-pound weight loss, fatigue, anorexia, and avoidance of food.

Her past medical and surgical history were significant for hypertension, depression, appendectomy, laparoscopic ovarian cystectomy (of benign histology), and cholelithiasis. Her medication list consisted of pindolol and sertraline. Her physical exam was remarkable for abdominal distention, palpable mass, fluid wave, shifting dullness, and hypoactive bowel sounds. There was no tenderness or organomegaly. She had a mild microcytic anemia with no leukocytosis. Liver chemistries and electrolytes were normal. The erythrocyte sedimentation rate was 51. The initial CT scan of the abdomen is shown at right. TH

What is the most likely differential diagnosis?

1. Pneumatosis intestinalis;
2. Ovarian carcinoma or peritoneal carcinomatosis;
3. Sclerosing mesenteritis;
4. Spontaneous bacterial peritonitis; or
5. Lymphoma.

Discussion

The answer is C: sclerosing mesenteritis (SM). The CT scan shows a bulky heterogeneous mesenteric mass measuring approximately 8.7 x 6 x 10 cm, with a focal, 2-cm calcification at the lateral margin. The mass began at the proximal superior mesenteric artery, extended inferiorly to the top of the pelvis, and encased the body of the pancreas, central mesenteric vessels and the confluence of the portal, splenic, and superior mesenteric veins (SMV). The SMV was poorly visualized and may have been compressed or occluded by the mass. Diffuse abdominal and pelvic ascites also were seen.

Results of a needle biopsy of the mesenteric mass showed fibrous tissue and a mixed population of B cells and T cells consistent with sclerosing mesenteritis, a fibroinflammatory reactive process.

Sclerosing or retractile mesenteritis is an uncommon, idiopathic, nonneoplastic, tumor-like lesion that thickens and shortens the mesentery.1 The condition consists of a pathophysiological spectrum of disease, the classification of which is based on the predominant histological finding on tissue biopsy. Cases in which the predominant findings are fatty degeneration and necrosis are known as the mesenteric lipodystrophy variant; those in which chronic inflammation predominates are known as the mesenteric panniculitis variant; and finally, the predominantly fibrotic form is known as the retractile mesenteritis or mesenteric fibrosis variant.

The presence of some degree of fibrosis, chronic inflammation, and fat necrosis in all three lesions, as well as their common demographic and clinical characteristics, suggest that the three diagnostic groups represent a single clinical entity.2 Sclerosing mesenteritis is used as an umbrella term that encompasses all three histologic variants.

Numerous theories exist to explain the pathogenesis of the condition, most commonly relating to a non-specific reaction to mesenteric injuries such as antecedent surgery or abdominal trauma, or possibly autoimmunity, ischemia/infection, and or paraneoplastic phenomena.

A study of 68 cases of mesenteric panniculitis undertaken by Durst, et al., showed that the age range is diverse, affecting patients from seven to 82 years.3 In another study, Emory, et al., reported an average age of 60.1 years at presentation.2 In both studies there was a slight male preponderance, with a male: female ratio of 1.9:1, and 1.8:1.2,3

In the largest reported experience with patients with sclerosing mesenteritis from a single institution, the majority were male (72%) with an age range of 34-87 years.10,11 Of these patients, the most common presenting complaints are abdominal pain (36%-67%), vomiting (18%-32%), palpable abdominal mass (16%), anorexia (7%-17%), weight loss (14%-45%), constipation (8%-15%), diarrhea (7%-26%), and rectal bleeding (5%). The duration of symptoms varies from 24 hours to two years.3-10 In most cases, the blood chemistry and urinalysis were reported to be normal, although an elevated sedimentation rate has been reported in a minority.3,11

Diagnosis usually depends on imaging studies (most often CT scan) and pathological review of biopsy specimens. Concurrent pathology is found in 18%-25% of cases, including lymphoma (7%), cholelithiasis (4%), cirrhosis of the liver (3%), and abdominal aortic aneurysm (3%).3,10 Other conditions associated with idiopathic fibrosis, such as retroperitoneal fibrosis and sclerosing pancreatitis, have been reported to occur together with SM.4,10

To date, treatment options are guided by anecdotal experience and reports of open label clinical results.10,11 Clinical and experimental studies have suggested a possible hormonal influence on fibrous proliferation in retroperitoneal fibrosis, which led to the discovery of the beneficial effect of anti-estrogenic treatment with tamoxifen.5,6 Clark, et al., had noticed that tamoxifen was successfully used in the treatment of desmoid tumors and then reported its use in two cases of retroperitoneal fibrosis.5 Others have since used tamoxifen in sclerosing mesenteritis, including a relatively large experience from our institution that suggests the combination of tamoxifen with a prednisone taper may be the most beneficial treatment for this condition.7,10,11

Other treatments that have been reported to be of some benefit include combination of corticosteroids and colchicine or azathioprine, although these reports include very small numbers of patients.8,10 Ginsburg, et al., reported their experience with thalidomide in a short term, open-label study in five symptomatic subjects.12 Four patients (80%) experienced an improvement in symptoms, and one achieved complete remission by week four, which was sustained. There was also a decrease in inflammatory markers, although no changes were noted on follow-up CT scans.

The natural history of sclerosing mesenteritis is quite variable, with a few patients undergoing spontaneous remission, many experiencing an indolent course, and others progressing to bowel obstruction or other complications, including chylous ascites, mesenteric venous or arterial occlusion, and malnutrition (often resulting in the need for parenteral nutrition).10,11 There have been fatal cases of this condition reported in the literature; however, Durst, et al., found that of 40 patients undergoing exploratory laparotomy and biopsy, only one patient died as a direct result of the disease after 12 years and several explorations.9-11 In the remaining 39 patients, their symptoms resolved without any further treatment, although in some the abdominal mass was persistently palpable.3. Similarly Emory, et al., found that after following 42 patients for an average of 9.5 years, only three patients had complications that resulted in death, all of which occurred in the postoperative period.2

In our experience, three of 92 patients (3%) died from causes that were thought to be attributable to sclerosing mesenteritis or its treatment.10,11

In summary, sclerosing mesenteritis is a rare disease entity that thickens and shortens the mesentery due to a non-specific fibroinflammatory reaction in the mesentery. Diagnosis relies on CT scanning and tissue biopsy, which shows variable degrees of fibrosis, chronic inflammation, and fat necrosis. Treatment options are based on anecdotal experience only. Tamoxifen, with or without combination therapy with prednisone, colchicine, azathioprine, and thalidomide, appears to be of some benefit. Prognosis is variable, with some patients achieving remission while others die from complications related to disease progression such as bowel obstruction, mesenteric vascular occlusion, and malnutrition; however, many have persistent symptoms that may improve but not resolve with medical therapy. TH

References

1. Kelly JK, Hwang WS. Idiopathic retractile (sclerosing) mesenteritis and its differential diagnosis. Am J Surg Pathol. 1989;13(6):513-521.
2. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol. 1997 Apr;21(4):392.
3. Durst AL, Freund H, Rosenmann E, et al. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery. 1977;81:203.
4. Chew CK, Jarzylo SV, Valberg LS. Idiopathic retroperitoneal fibrosis with protein-losing enteropathy and duodenal obstruction successfully treated with corticosteroids. Can Med Assoc J. 1966;95(23):1183-1188.
5. Clark CP, Vanderpool D, Preskitt JT. The response of retroperitoneal fibrosis to tamoxifen. Surgery. 1991 Apr;109(4):502-506.
6. Owens LV, Cance WG, Huth JF. Retroperitoneal fibrosis treated with tamoxifen. Am Surg. 1995;61:842-844.
7. Venkataramani A, Behling CA, Lynche KD. Sclerosing mesenteritis: an unusual cause of abdominal pain in an HIV-positive patient. Am J Gastroenterol. 1997 Jun;92(6):1059-1060.
8. Genereau T, Bellin MF, Wechsler B. Demonstration of efficacy of combining corticosteroids and colchicine in two patients with idiopathic sclerosing mesenteritis. Dig Dis Sci. 1996;41(4):684-688.
9. Andersen JA, Rasmussen NR, Pedersen JK. Mesenteric panniculitis: a fatal case. Am J Gastroenterol. 1982 Jul;77(7):523-525.
10. Akram S, Pardi DS, Smyrk TC. Sclerosing mesenteritis: The Mayo Clinic Experience. (Clinical features and tx response) Gastroenterology. 2003;A-190.
11. Akram S, Pardi DS, Smyrk TC. Effect of tamoxifen on clinical course of sclerosing mesenteritis. Gastroenterology. 2006;130:A-322.
12. Ginsburg PM, Ehrenpreis ED. A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis. Aliment Pharmacol Ther. 2002 Dec;16(12):2115-2122.

Historic Puzzler #3: The Root of the Problem

In 1777 G.F. was traveling through the South Pacific Islands as a naturalist. He witnessed a ceremony that involved a substance being “ … made in the most disgustful [sic] manner that can be imagined, from the roots of a species of pepper-tree. The root is cut small and the pieces chewed by several people, who spit the macerated mass into a bowl. … They strain it through a quantity of fibers … and mix with the coconut milk. They swallow this nauseous stuff as fast as possible; and some old topes value themselves on being able to empty a great number of bowls.”

Who was GF, the captain of this expedition, and what was the root?

Recent reports suggest possible hepatotoxicity from this substance. For extra credit, what are the dermatologic and neuro-ophthalmologic side effects of chronic heavy ingestion?

A58-year-old white female presented with an eight-month history of progressive lower abdominal pain and bloating. She experienced intermittent constipation followed by a five-month period of persistent loose, watery diarrhea, a 35-pound weight loss, fatigue, anorexia, and avoidance of food.

Her past medical and surgical history were significant for hypertension, depression, appendectomy, laparoscopic ovarian cystectomy (of benign histology), and cholelithiasis. Her medication list consisted of pindolol and sertraline. Her physical exam was remarkable for abdominal distention, palpable mass, fluid wave, shifting dullness, and hypoactive bowel sounds. There was no tenderness or organomegaly. She had a mild microcytic anemia with no leukocytosis. Liver chemistries and electrolytes were normal. The erythrocyte sedimentation rate was 51. The initial CT scan of the abdomen is shown at right. TH

What is the most likely differential diagnosis?

1. Pneumatosis intestinalis;
2. Ovarian carcinoma or peritoneal carcinomatosis;
3. Sclerosing mesenteritis;
4. Spontaneous bacterial peritonitis; or
5. Lymphoma.

Discussion

The answer is C: sclerosing mesenteritis (SM). The CT scan shows a bulky heterogeneous mesenteric mass measuring approximately 8.7 x 6 x 10 cm, with a focal, 2-cm calcification at the lateral margin. The mass began at the proximal superior mesenteric artery, extended inferiorly to the top of the pelvis, and encased the body of the pancreas, central mesenteric vessels and the confluence of the portal, splenic, and superior mesenteric veins (SMV). The SMV was poorly visualized and may have been compressed or occluded by the mass. Diffuse abdominal and pelvic ascites also were seen.

Results of a needle biopsy of the mesenteric mass showed fibrous tissue and a mixed population of B cells and T cells consistent with sclerosing mesenteritis, a fibroinflammatory reactive process.

Sclerosing or retractile mesenteritis is an uncommon, idiopathic, nonneoplastic, tumor-like lesion that thickens and shortens the mesentery.1 The condition consists of a pathophysiological spectrum of disease, the classification of which is based on the predominant histological finding on tissue biopsy. Cases in which the predominant findings are fatty degeneration and necrosis are known as the mesenteric lipodystrophy variant; those in which chronic inflammation predominates are known as the mesenteric panniculitis variant; and finally, the predominantly fibrotic form is known as the retractile mesenteritis or mesenteric fibrosis variant.

The presence of some degree of fibrosis, chronic inflammation, and fat necrosis in all three lesions, as well as their common demographic and clinical characteristics, suggest that the three diagnostic groups represent a single clinical entity.2 Sclerosing mesenteritis is used as an umbrella term that encompasses all three histologic variants.

Numerous theories exist to explain the pathogenesis of the condition, most commonly relating to a non-specific reaction to mesenteric injuries such as antecedent surgery or abdominal trauma, or possibly autoimmunity, ischemia/infection, and or paraneoplastic phenomena.

A study of 68 cases of mesenteric panniculitis undertaken by Durst, et al., showed that the age range is diverse, affecting patients from seven to 82 years.3 In another study, Emory, et al., reported an average age of 60.1 years at presentation.2 In both studies there was a slight male preponderance, with a male: female ratio of 1.9:1, and 1.8:1.2,3

In the largest reported experience with patients with sclerosing mesenteritis from a single institution, the majority were male (72%) with an age range of 34-87 years.10,11 Of these patients, the most common presenting complaints are abdominal pain (36%-67%), vomiting (18%-32%), palpable abdominal mass (16%), anorexia (7%-17%), weight loss (14%-45%), constipation (8%-15%), diarrhea (7%-26%), and rectal bleeding (5%). The duration of symptoms varies from 24 hours to two years.3-10 In most cases, the blood chemistry and urinalysis were reported to be normal, although an elevated sedimentation rate has been reported in a minority.3,11

Diagnosis usually depends on imaging studies (most often CT scan) and pathological review of biopsy specimens. Concurrent pathology is found in 18%-25% of cases, including lymphoma (7%), cholelithiasis (4%), cirrhosis of the liver (3%), and abdominal aortic aneurysm (3%).3,10 Other conditions associated with idiopathic fibrosis, such as retroperitoneal fibrosis and sclerosing pancreatitis, have been reported to occur together with SM.4,10

To date, treatment options are guided by anecdotal experience and reports of open label clinical results.10,11 Clinical and experimental studies have suggested a possible hormonal influence on fibrous proliferation in retroperitoneal fibrosis, which led to the discovery of the beneficial effect of anti-estrogenic treatment with tamoxifen.5,6 Clark, et al., had noticed that tamoxifen was successfully used in the treatment of desmoid tumors and then reported its use in two cases of retroperitoneal fibrosis.5 Others have since used tamoxifen in sclerosing mesenteritis, including a relatively large experience from our institution that suggests the combination of tamoxifen with a prednisone taper may be the most beneficial treatment for this condition.7,10,11

Other treatments that have been reported to be of some benefit include combination of corticosteroids and colchicine or azathioprine, although these reports include very small numbers of patients.8,10 Ginsburg, et al., reported their experience with thalidomide in a short term, open-label study in five symptomatic subjects.12 Four patients (80%) experienced an improvement in symptoms, and one achieved complete remission by week four, which was sustained. There was also a decrease in inflammatory markers, although no changes were noted on follow-up CT scans.

The natural history of sclerosing mesenteritis is quite variable, with a few patients undergoing spontaneous remission, many experiencing an indolent course, and others progressing to bowel obstruction or other complications, including chylous ascites, mesenteric venous or arterial occlusion, and malnutrition (often resulting in the need for parenteral nutrition).10,11 There have been fatal cases of this condition reported in the literature; however, Durst, et al., found that of 40 patients undergoing exploratory laparotomy and biopsy, only one patient died as a direct result of the disease after 12 years and several explorations.9-11 In the remaining 39 patients, their symptoms resolved without any further treatment, although in some the abdominal mass was persistently palpable.3. Similarly Emory, et al., found that after following 42 patients for an average of 9.5 years, only three patients had complications that resulted in death, all of which occurred in the postoperative period.2

In our experience, three of 92 patients (3%) died from causes that were thought to be attributable to sclerosing mesenteritis or its treatment.10,11

In summary, sclerosing mesenteritis is a rare disease entity that thickens and shortens the mesentery due to a non-specific fibroinflammatory reaction in the mesentery. Diagnosis relies on CT scanning and tissue biopsy, which shows variable degrees of fibrosis, chronic inflammation, and fat necrosis. Treatment options are based on anecdotal experience only. Tamoxifen, with or without combination therapy with prednisone, colchicine, azathioprine, and thalidomide, appears to be of some benefit. Prognosis is variable, with some patients achieving remission while others die from complications related to disease progression such as bowel obstruction, mesenteric vascular occlusion, and malnutrition; however, many have persistent symptoms that may improve but not resolve with medical therapy. TH

References

1. Kelly JK, Hwang WS. Idiopathic retractile (sclerosing) mesenteritis and its differential diagnosis. Am J Surg Pathol. 1989;13(6):513-521.
2. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol. 1997 Apr;21(4):392.
3. Durst AL, Freund H, Rosenmann E, et al. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery. 1977;81:203.
4. Chew CK, Jarzylo SV, Valberg LS. Idiopathic retroperitoneal fibrosis with protein-losing enteropathy and duodenal obstruction successfully treated with corticosteroids. Can Med Assoc J. 1966;95(23):1183-1188.
5. Clark CP, Vanderpool D, Preskitt JT. The response of retroperitoneal fibrosis to tamoxifen. Surgery. 1991 Apr;109(4):502-506.
6. Owens LV, Cance WG, Huth JF. Retroperitoneal fibrosis treated with tamoxifen. Am Surg. 1995;61:842-844.
7. Venkataramani A, Behling CA, Lynche KD. Sclerosing mesenteritis: an unusual cause of abdominal pain in an HIV-positive patient. Am J Gastroenterol. 1997 Jun;92(6):1059-1060.
8. Genereau T, Bellin MF, Wechsler B. Demonstration of efficacy of combining corticosteroids and colchicine in two patients with idiopathic sclerosing mesenteritis. Dig Dis Sci. 1996;41(4):684-688.
9. Andersen JA, Rasmussen NR, Pedersen JK. Mesenteric panniculitis: a fatal case. Am J Gastroenterol. 1982 Jul;77(7):523-525.
10. Akram S, Pardi DS, Smyrk TC. Sclerosing mesenteritis: The Mayo Clinic Experience. (Clinical features and tx response) Gastroenterology. 2003;A-190.
11. Akram S, Pardi DS, Smyrk TC. Effect of tamoxifen on clinical course of sclerosing mesenteritis. Gastroenterology. 2006;130:A-322.
12. Ginsburg PM, Ehrenpreis ED. A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis. Aliment Pharmacol Ther. 2002 Dec;16(12):2115-2122.

Historic Puzzler #3: The Root of the Problem

In 1777 G.F. was traveling through the South Pacific Islands as a naturalist. He witnessed a ceremony that involved a substance being “ … made in the most disgustful [sic] manner that can be imagined, from the roots of a species of pepper-tree. The root is cut small and the pieces chewed by several people, who spit the macerated mass into a bowl. … They strain it through a quantity of fibers … and mix with the coconut milk. They swallow this nauseous stuff as fast as possible; and some old topes value themselves on being able to empty a great number of bowls.”

Who was GF, the captain of this expedition, and what was the root?

Recent reports suggest possible hepatotoxicity from this substance. For extra credit, what are the dermatologic and neuro-ophthalmologic side effects of chronic heavy ingestion?

If hospital medicine had to be associated with a single generation, it would most likely be generation X. According to SHM’s recently released 2005-2006 “Survey of Hospitalist Productivity and Compensation,” the average age of hospitalists is 37—the current average age of generation X. But more than the same life stage, this generation shares common characteristics, perspectives, and habits that seem consistent with hospitalists of all ages.

Meet Generation X

Generation X is the term for the generation born between 1965 and 1976. Because they were influenced by the same world events and social trends, this generation (as all generations) brings its own traits and values to the workplace. “The career hallmarks of this generation include their independence and enterprising desire to make things happen,” says Devon Scheef, a partner in The Learning Café ([email protected]), a consulting firm that specializes in helping managers overcome generational differences.

According to The Learning Café, the 51 million members of generation X grew up in a much different world than previous generations. Divorce and two-income families created latchkey kids out of many in this generation, leading to traits of independence, resilience, and adaptability. Members of generation X feel strongly that they don't need someone looking over their shoulders.

This independence can make hospital medicine especially appealing to young physicians because they can often structure their daily work to suit themselves.

When Work Ethics Collide

Generation X and baby boomer workers most often butt heads over differing work ethics. This is true across all industries, including the medical field—in hospitals and other healthcare settings. Baby boomers tend to put in long hours and devote themselves to their work. “They [baby boomers] work hard—maybe too hard,” says Diane Thielfoldt, partner in The Learning Café. “This is the generation that increased our workweek from 40 hours to 70 or 80 hours.” And baby boomers often expect this level of dedication from their colleagues.

Generation Xers are not interested in working these hours; they do not equate long hours with job efficiency. One of the big draws of hospital medicine is the flexible schedule; a young physician can work a set schedule, such as seven-on, seven-off, and know that when she’s not working, she’s free to do what she wants.

Of generation X physicians, Lawrence G. Smith, FACP, chief academic officer, North Shore-Long Island Jewish Health System, says, “Led by women, this generation of [medical] students will work fewer hours and demand flexible employment opportunities.”1

Young physicians who choose private practice or other specialties may find it difficult to fight the work ethic expectations of older physicians and administrators. “Aging boomers—a terrible term for those in the 46- to 55-year-old bracket—have really run into a wall of work-life balance,” Scheef points out. “They are scaling back on work and looking ahead to retirement. This is hard for this go-go generation. Many are looking to the younger generation—we hear this in healthcare, particularly—to lighten their workload.”

How Generation X Works

Contrary to what many baby boomer bosses may think, members of generation X are terrific employees. They simply have their own way of getting things done.

“Gen Xers are in a new stage of life now, in their mid- to late 30s, and we’re seeing some interesting trends,” says Thielfoldt. “Gen Xers have an entrepreneurial spirit. This trend has become stronger as the generation has gotten older, which is surprising.” Some young hospitalists have taken this trend to the extreme, founding their own hospital medicine groups; others build their careers by creating and running new projects and committees. “They seem very oriented to ownership and accountability to define, create, and implement in their careers,” continues Thielfoldt. “Gen Xers are driven out of organizations when asked to focus on just one piece of the process.” Again, this fits in with the hospitalist personality.

At the same time, generation X values learning new skills or specialties. “As a generation, they tend to be very portfolio-oriented, in any industry,” says Thielfoldt. “They want to build a skills portfolio as they would a financial portfolio. They want expertise and new skills. This is more important to them than how much or how little time they work.”

Generation X may also find hospital medicine to be the perfect job because the management style suits them so well. “Gen Xers are very sensitive to micromanaging,” says Scheef. “And now that they have the confidence of experience, [the negative reaction to micromanaging by a supervisor] is worse. Instead of traditional managing, they are very receptive to expert coaching or formal mentoring. This can tie in really well with helping them develop that skills portfolio.”

Changes Are Coming

As more baby boomers retire and generation X becomes firmly established, healthcare and other industries may change the way they operate. “Gen Xers have growing families now. They have come to the work-life balance issue much earlier than any other generation,” says Thielfoldt. “And unlike previous generations, their top priority is spending time with their children. That sounds crazy, right? Boomers have doted on their children—but they spend their time at work, especially fathers. Gen X fathers spend more time on average with their kids than boomers did at the same age.” The eventual outcome: “Employers need to respect this as a top priority and provide flexible scheduling to allow it.”

Many hospital medicine programs are doing just that, searching for ways to adequately cover the patient census and workload and keep hospitalists happy.

Dr. Smith agrees that change must come to healthcare: “The future environment … must recognize that physician well-being and balance in life is a valid and important concern and does not negate the attainment of professionalism. It must reward excellence, not endurance.”1 TH

Jane Jerrard regularly writes “Career Development.”

References

1. Smith, LG. Medical professionalism and the generation gap. Am J Med. 2005 Apr;118(4):439-442.

If hospital medicine had to be associated with a single generation, it would most likely be generation X. According to SHM’s recently released 2005-2006 “Survey of Hospitalist Productivity and Compensation,” the average age of hospitalists is 37—the current average age of generation X. But more than the same life stage, this generation shares common characteristics, perspectives, and habits that seem consistent with hospitalists of all ages.

Meet Generation X

Generation X is the term for the generation born between 1965 and 1976. Because they were influenced by the same world events and social trends, this generation (as all generations) brings its own traits and values to the workplace. “The career hallmarks of this generation include their independence and enterprising desire to make things happen,” says Devon Scheef, a partner in The Learning Café ([email protected]), a consulting firm that specializes in helping managers overcome generational differences.

According to The Learning Café, the 51 million members of generation X grew up in a much different world than previous generations. Divorce and two-income families created latchkey kids out of many in this generation, leading to traits of independence, resilience, and adaptability. Members of generation X feel strongly that they don't need someone looking over their shoulders.

This independence can make hospital medicine especially appealing to young physicians because they can often structure their daily work to suit themselves.

When Work Ethics Collide

Generation X and baby boomer workers most often butt heads over differing work ethics. This is true across all industries, including the medical field—in hospitals and other healthcare settings. Baby boomers tend to put in long hours and devote themselves to their work. “They [baby boomers] work hard—maybe too hard,” says Diane Thielfoldt, partner in The Learning Café. “This is the generation that increased our workweek from 40 hours to 70 or 80 hours.” And baby boomers often expect this level of dedication from their colleagues.

Generation Xers are not interested in working these hours; they do not equate long hours with job efficiency. One of the big draws of hospital medicine is the flexible schedule; a young physician can work a set schedule, such as seven-on, seven-off, and know that when she’s not working, she’s free to do what she wants.

Of generation X physicians, Lawrence G. Smith, FACP, chief academic officer, North Shore-Long Island Jewish Health System, says, “Led by women, this generation of [medical] students will work fewer hours and demand flexible employment opportunities.”1

Young physicians who choose private practice or other specialties may find it difficult to fight the work ethic expectations of older physicians and administrators. “Aging boomers—a terrible term for those in the 46- to 55-year-old bracket—have really run into a wall of work-life balance,” Scheef points out. “They are scaling back on work and looking ahead to retirement. This is hard for this go-go generation. Many are looking to the younger generation—we hear this in healthcare, particularly—to lighten their workload.”

How Generation X Works

Contrary to what many baby boomer bosses may think, members of generation X are terrific employees. They simply have their own way of getting things done.

“Gen Xers are in a new stage of life now, in their mid- to late 30s, and we’re seeing some interesting trends,” says Thielfoldt. “Gen Xers have an entrepreneurial spirit. This trend has become stronger as the generation has gotten older, which is surprising.” Some young hospitalists have taken this trend to the extreme, founding their own hospital medicine groups; others build their careers by creating and running new projects and committees. “They seem very oriented to ownership and accountability to define, create, and implement in their careers,” continues Thielfoldt. “Gen Xers are driven out of organizations when asked to focus on just one piece of the process.” Again, this fits in with the hospitalist personality.

At the same time, generation X values learning new skills or specialties. “As a generation, they tend to be very portfolio-oriented, in any industry,” says Thielfoldt. “They want to build a skills portfolio as they would a financial portfolio. They want expertise and new skills. This is more important to them than how much or how little time they work.”

Generation X may also find hospital medicine to be the perfect job because the management style suits them so well. “Gen Xers are very sensitive to micromanaging,” says Scheef. “And now that they have the confidence of experience, [the negative reaction to micromanaging by a supervisor] is worse. Instead of traditional managing, they are very receptive to expert coaching or formal mentoring. This can tie in really well with helping them develop that skills portfolio.”

Changes Are Coming

As more baby boomers retire and generation X becomes firmly established, healthcare and other industries may change the way they operate. “Gen Xers have growing families now. They have come to the work-life balance issue much earlier than any other generation,” says Thielfoldt. “And unlike previous generations, their top priority is spending time with their children. That sounds crazy, right? Boomers have doted on their children—but they spend their time at work, especially fathers. Gen X fathers spend more time on average with their kids than boomers did at the same age.” The eventual outcome: “Employers need to respect this as a top priority and provide flexible scheduling to allow it.”

Many hospital medicine programs are doing just that, searching for ways to adequately cover the patient census and workload and keep hospitalists happy.

Dr. Smith agrees that change must come to healthcare: “The future environment … must recognize that physician well-being and balance in life is a valid and important concern and does not negate the attainment of professionalism. It must reward excellence, not endurance.”1 TH

Jane Jerrard regularly writes “Career Development.”

References

1. Smith, LG. Medical professionalism and the generation gap. Am J Med. 2005 Apr;118(4):439-442.

If hospital medicine had to be associated with a single generation, it would most likely be generation X. According to SHM’s recently released 2005-2006 “Survey of Hospitalist Productivity and Compensation,” the average age of hospitalists is 37—the current average age of generation X. But more than the same life stage, this generation shares common characteristics, perspectives, and habits that seem consistent with hospitalists of all ages.

Meet Generation X

Generation X is the term for the generation born between 1965 and 1976. Because they were influenced by the same world events and social trends, this generation (as all generations) brings its own traits and values to the workplace. “The career hallmarks of this generation include their independence and enterprising desire to make things happen,” says Devon Scheef, a partner in The Learning Café ([email protected]), a consulting firm that specializes in helping managers overcome generational differences.

According to The Learning Café, the 51 million members of generation X grew up in a much different world than previous generations. Divorce and two-income families created latchkey kids out of many in this generation, leading to traits of independence, resilience, and adaptability. Members of generation X feel strongly that they don't need someone looking over their shoulders.

This independence can make hospital medicine especially appealing to young physicians because they can often structure their daily work to suit themselves.

When Work Ethics Collide

Generation X and baby boomer workers most often butt heads over differing work ethics. This is true across all industries, including the medical field—in hospitals and other healthcare settings. Baby boomers tend to put in long hours and devote themselves to their work. “They [baby boomers] work hard—maybe too hard,” says Diane Thielfoldt, partner in The Learning Café. “This is the generation that increased our workweek from 40 hours to 70 or 80 hours.” And baby boomers often expect this level of dedication from their colleagues.

Generation Xers are not interested in working these hours; they do not equate long hours with job efficiency. One of the big draws of hospital medicine is the flexible schedule; a young physician can work a set schedule, such as seven-on, seven-off, and know that when she’s not working, she’s free to do what she wants.

Of generation X physicians, Lawrence G. Smith, FACP, chief academic officer, North Shore-Long Island Jewish Health System, says, “Led by women, this generation of [medical] students will work fewer hours and demand flexible employment opportunities.”1

Young physicians who choose private practice or other specialties may find it difficult to fight the work ethic expectations of older physicians and administrators. “Aging boomers—a terrible term for those in the 46- to 55-year-old bracket—have really run into a wall of work-life balance,” Scheef points out. “They are scaling back on work and looking ahead to retirement. This is hard for this go-go generation. Many are looking to the younger generation—we hear this in healthcare, particularly—to lighten their workload.”

How Generation X Works

Contrary to what many baby boomer bosses may think, members of generation X are terrific employees. They simply have their own way of getting things done.

“Gen Xers are in a new stage of life now, in their mid- to late 30s, and we’re seeing some interesting trends,” says Thielfoldt. “Gen Xers have an entrepreneurial spirit. This trend has become stronger as the generation has gotten older, which is surprising.” Some young hospitalists have taken this trend to the extreme, founding their own hospital medicine groups; others build their careers by creating and running new projects and committees. “They seem very oriented to ownership and accountability to define, create, and implement in their careers,” continues Thielfoldt. “Gen Xers are driven out of organizations when asked to focus on just one piece of the process.” Again, this fits in with the hospitalist personality.

At the same time, generation X values learning new skills or specialties. “As a generation, they tend to be very portfolio-oriented, in any industry,” says Thielfoldt. “They want to build a skills portfolio as they would a financial portfolio. They want expertise and new skills. This is more important to them than how much or how little time they work.”

Generation X may also find hospital medicine to be the perfect job because the management style suits them so well. “Gen Xers are very sensitive to micromanaging,” says Scheef. “And now that they have the confidence of experience, [the negative reaction to micromanaging by a supervisor] is worse. Instead of traditional managing, they are very receptive to expert coaching or formal mentoring. This can tie in really well with helping them develop that skills portfolio.”

Changes Are Coming

As more baby boomers retire and generation X becomes firmly established, healthcare and other industries may change the way they operate. “Gen Xers have growing families now. They have come to the work-life balance issue much earlier than any other generation,” says Thielfoldt. “And unlike previous generations, their top priority is spending time with their children. That sounds crazy, right? Boomers have doted on their children—but they spend their time at work, especially fathers. Gen X fathers spend more time on average with their kids than boomers did at the same age.” The eventual outcome: “Employers need to respect this as a top priority and provide flexible scheduling to allow it.”

Many hospital medicine programs are doing just that, searching for ways to adequately cover the patient census and workload and keep hospitalists happy.

Dr. Smith agrees that change must come to healthcare: “The future environment … must recognize that physician well-being and balance in life is a valid and important concern and does not negate the attainment of professionalism. It must reward excellence, not endurance.”1 TH

Jane Jerrard regularly writes “Career Development.”

References

1. Smith, LG. Medical professionalism and the generation gap. Am J Med. 2005 Apr;118(4):439-442.

Federal officials are increasingly embracing pay for performance (P4P) in an effort to promote high-quality, cost effective care in government health programs. As the Centers for Medicaid and Medicare Services (CMS) and Congress move forward to implement this concept, SHM is working to ensure that the views of hospitalists are represented in this important debate.

More than 100 P4P programs are already up and running in the private sector in an attempt to reward quality healthcare by setting different payment levels for providers based on how well they meet benchmarks of quality and efficiency. CMS is testing the feasibility of applying this concept to the Medicare program through a number of initiatives.

SHM’s Public Policy and Hospital Quality and Patient Safety committees have been involved in evaluating CMS’ Physician Voluntary Reporting Program (PVRP), launched earlier this year and widely believed to be the precursor to an eventual P4P program for physicians’ services. Under this initiative, physicians are encouraged to submit quality data on a “starter set” of 16 evidence-based measures for certain primary care, surgery, nephrology, and emergency medical services. Physicians who participate in the program receive confidential reports on their performance.

click for large version

SHM has recommended that hospitalists register their intent to report and begin reporting on relevant performance measures to the extent practicable as a way of becoming more familiar with the program. Because these initial 16 measures have only limited relevance to services billed by hospitalists, SHM is engaged in discussions with lawmakers and their staffs, CMS officials, and consensus organizations involved in developing quality measures, to expand the program’s scope.

As part of Advocacy Day on May 3, some 70 SHM members met with legislators and their staffs and conveyed SHM’s support for initiatives like the PVRP that seek to measure resource use and improve quality, to attain better value for the Medicare program. (See coverage in The Hospitalist SHM Meeting Reporter, July 2006, p. 1.) Participants also educated lawmakers on the role of hospitalists in helping their institutions meet quality reporting requirements mandated under the Medicare Modernization Act, which ties annual hospital payment updates to the submission of performance data for 10 quality measures. The participants also expressed SHM’s interest in working with CMS on demonstration projects that assess the contributions of hospital medicine programs to improved patient care and more efficient management of hospital resources.

In addition to Congress and CMS, non-governmental groups such as the National Quality Forum (NQF), the American Medical Association Physician Consortium for Performance Improvement (PCPI), and the Ambulatory Care Quality Alliance are actively engaged in providing input to CMS on the PVRP and other P4P-related initiatives. SHM has joined the PCPI, which works with medical specialty organizations to develop physician-level performance measures.

As a new member of the PCPI, SHM submitted feedback during the public comment period on perioperative care measures, the development of which was led by the American College of Surgeons, along with input from other medical specialties. SHM will also participate in two upcoming workgroups—one on emergency medicine, which will focus on treating for MI and pneumonia, and another on geriatrics, which will look at falls, urinary incontinence, and end-of-life care. At least through 2006, the PCPI is focusing on measures that fall under the CMS contract and will be included in the PVRP.

SHM is also a member of the NQF, a nonprofit organization that Congress has charged with endorsing consensus-based national standards for measurement and public reporting of healthcare performance data. NQF is seeking nominations for members of the steering committee and technical advisory panels that will oversee the work on new consensus standards for hospital care. This project, sponsored by the AHRQ, will address issues of patient safety, pediatrics, and inpatient care. SHM will submit nominations during this process and plans to be fully engaged.

To further develop its agenda on performance and quality standards in inpatient hospital care, SHM recently established a new Performance and Standards Task Force. This task force is charged with developing a coordinated approach for SHM to work with external organizations in the performance and standards and quality arena and comprises the chairs of the PPC and HQPS committees and other SHM leaders active in organizations like the JCAHO and the IHI.

P4P is here to stay. SHM is well positioned to influence the development and implementation of inpatient quality measures that may eventually become part of a Medicare P4P program for physician services. TH

Allendorf is senior advisor for Advocacy and Government Affairs at SHM. Epstein is senior advisor for Quality Standards and Compliance at SHM.

SHM: BEHIND THE SCENES

How SHM Manages Your Money

By Steven Poitras

In the past three months you have read articles from my peers, including one by Todd Von Deak concerning the great strides he is making in the membership department by ensuring that we are generating the most benefits for our members; one from Scott Johnson, who is taking us into the future with regard to information services; and from Geri Barnes, our education and quality initiatives director, who is helping drive our organizational mission of promoting excellence in the practice of hospital medicine.

This month I want to tell you about our organization, its structure, and what we are collectively doing to ensure that the dues and grants we receive are put to good use to benefit our members and ensure our place in driving hospital medicine forward.

Studies show that 70% of small businesses and small non-profit organizations survive their first year, 30% survive their second year, and only 20% survive after five years. SHM will celebrate its 10th year in 2007. Congratulations and thank you. It’s you, our members, who have taken us this far. It’s you, our members, who will take us into the next 10, 20, 50 years, and beyond. We are not the same organization we were 10 years ago, and I suspect we will not be the same organization in 10 years that we are today.

Over the years I have worked and consulted in many organizations ranging from small mom-and-pops to large, multinational corporations. More often than not, despite a common desire to succeed, conflict exists within various constituencies (e.g., employees, executive management, board of directors) that leads to differing opinions on the best strategy for the company moving forward. I’m proud to say that this isn’t the case with SHM.

We have formulated a business model that uses tried-and-true corporate tools to ensure our members receive the maximum possible value in areas of the greatest impact. It encompasses both our paid and non-paid staff and volunteers to validate what matters most. Your dollars are put to good use. We concentrate on doing things that can be done and done well. If it’s a great idea but doesn’t get to the heart of what our members need or want, we won’t siphon off money and time. We receive money from our members and grantors with the intent of fulfilling a promise or mission. We try to understand what can be accomplished, and then we apply our resources to those goals, ensuring that a higher percentage of those resources are going to mission critical programs and services.

Both our members and grantors look for a strong return on their investment for the monies they send and set aside for our cause. Performance standards are necessary, not only to ensure high level delivery of services but also to ensure our organization’s fiscal responsibility. We employ a staff with many qualifications and backgrounds and coordinate our efforts further with diverse, educated, and dedicated volunteers who are experts in their areas.

Not only is our staff concerned with producing measurable results attributed to the dollars we receive, but we are also measuring mission success in numeric terms other than profit and loss, most specifically within our education and quality initiatives as well as our membership departments. Together these departments are spearheading metrics initiatives that are, for the most part, completely new to our organization but essential to our growth. We involve our staff at all levels of the organization in the pursuit of obtaining these metrics. We strive to collaboratively fulfill SHM’s objectives, and our adaptability allows us to scan the external environment and respond to the ever-changing needs of our members and grantors. Consistency of these values and the internal systems from our information services department that support problem solving, efficiency, and effectiveness at every level across our organizational boundaries help us obtain fulfilling our mission.

Communication about our direction is provided at every opportunity: staff meetings, board meetings, brown-bag lunches, and one-on-one employee discussions. Teamwork is emphasized as the primary means for accomplishing work. When decisions need to be made, all employees and volunteers are sought for counsel and advice from them, their peers, and others who might have insight about our programs. Armed with knowledge, strategic and tactical objectives that are clearly defined and pursued with greater focus, conviction, and diligence our employees embrace the change that is so evident in our fast moving organization.

Everyone in our organization understands where we are going, how we intend to get there, and how he or she fits into our organization’s strategy. The culture of our organization has shifted, but our focus on the benefits of hospital medicine has remained constant. By utilizing these strategic planning tools and techniques, we are redeveloping and revitalizing our corporate mission statement by understanding our organizations strengths, weaknesses, opportunities, threats, and actual and potential competitive advantages. This allows us to move beyond just mere expectations to actually setting the standard by which everyone will be judged.

Our employees, volunteers, members, and grantors remind us that while the business is managed on a daily basis, during our strategic planning and project implementation we focus our strategy on the vital few rather than the trivial many. This allows us to put our organization on the right track for survival and long-term growth.

As we grow, we will search harder and further for experts to help us fulfill our promise of setting SHM as the standard in hospital medicine. I encourage your feedback. Please reach me at [email protected]. You will find that I am always accessible and open to your thoughts and ideas.

Next month you will hear from Laura Allendorf, senior advisor for advocacy and government affairs.

Poitras is director of Business Operations at SHM.

Federal officials are increasingly embracing pay for performance (P4P) in an effort to promote high-quality, cost effective care in government health programs. As the Centers for Medicaid and Medicare Services (CMS) and Congress move forward to implement this concept, SHM is working to ensure that the views of hospitalists are represented in this important debate.

More than 100 P4P programs are already up and running in the private sector in an attempt to reward quality healthcare by setting different payment levels for providers based on how well they meet benchmarks of quality and efficiency. CMS is testing the feasibility of applying this concept to the Medicare program through a number of initiatives.

SHM’s Public Policy and Hospital Quality and Patient Safety committees have been involved in evaluating CMS’ Physician Voluntary Reporting Program (PVRP), launched earlier this year and widely believed to be the precursor to an eventual P4P program for physicians’ services. Under this initiative, physicians are encouraged to submit quality data on a “starter set” of 16 evidence-based measures for certain primary care, surgery, nephrology, and emergency medical services. Physicians who participate in the program receive confidential reports on their performance.

click for large version

SHM has recommended that hospitalists register their intent to report and begin reporting on relevant performance measures to the extent practicable as a way of becoming more familiar with the program. Because these initial 16 measures have only limited relevance to services billed by hospitalists, SHM is engaged in discussions with lawmakers and their staffs, CMS officials, and consensus organizations involved in developing quality measures, to expand the program’s scope.

As part of Advocacy Day on May 3, some 70 SHM members met with legislators and their staffs and conveyed SHM’s support for initiatives like the PVRP that seek to measure resource use and improve quality, to attain better value for the Medicare program. (See coverage in The Hospitalist SHM Meeting Reporter, July 2006, p. 1.) Participants also educated lawmakers on the role of hospitalists in helping their institutions meet quality reporting requirements mandated under the Medicare Modernization Act, which ties annual hospital payment updates to the submission of performance data for 10 quality measures. The participants also expressed SHM’s interest in working with CMS on demonstration projects that assess the contributions of hospital medicine programs to improved patient care and more efficient management of hospital resources.

In addition to Congress and CMS, non-governmental groups such as the National Quality Forum (NQF), the American Medical Association Physician Consortium for Performance Improvement (PCPI), and the Ambulatory Care Quality Alliance are actively engaged in providing input to CMS on the PVRP and other P4P-related initiatives. SHM has joined the PCPI, which works with medical specialty organizations to develop physician-level performance measures.

As a new member of the PCPI, SHM submitted feedback during the public comment period on perioperative care measures, the development of which was led by the American College of Surgeons, along with input from other medical specialties. SHM will also participate in two upcoming workgroups—one on emergency medicine, which will focus on treating for MI and pneumonia, and another on geriatrics, which will look at falls, urinary incontinence, and end-of-life care. At least through 2006, the PCPI is focusing on measures that fall under the CMS contract and will be included in the PVRP.

SHM is also a member of the NQF, a nonprofit organization that Congress has charged with endorsing consensus-based national standards for measurement and public reporting of healthcare performance data. NQF is seeking nominations for members of the steering committee and technical advisory panels that will oversee the work on new consensus standards for hospital care. This project, sponsored by the AHRQ, will address issues of patient safety, pediatrics, and inpatient care. SHM will submit nominations during this process and plans to be fully engaged.

To further develop its agenda on performance and quality standards in inpatient hospital care, SHM recently established a new Performance and Standards Task Force. This task force is charged with developing a coordinated approach for SHM to work with external organizations in the performance and standards and quality arena and comprises the chairs of the PPC and HQPS committees and other SHM leaders active in organizations like the JCAHO and the IHI.

P4P is here to stay. SHM is well positioned to influence the development and implementation of inpatient quality measures that may eventually become part of a Medicare P4P program for physician services. TH

Allendorf is senior advisor for Advocacy and Government Affairs at SHM. Epstein is senior advisor for Quality Standards and Compliance at SHM.

SHM: BEHIND THE SCENES

How SHM Manages Your Money

By Steven Poitras

In the past three months you have read articles from my peers, including one by Todd Von Deak concerning the great strides he is making in the membership department by ensuring that we are generating the most benefits for our members; one from Scott Johnson, who is taking us into the future with regard to information services; and from Geri Barnes, our education and quality initiatives director, who is helping drive our organizational mission of promoting excellence in the practice of hospital medicine.

This month I want to tell you about our organization, its structure, and what we are collectively doing to ensure that the dues and grants we receive are put to good use to benefit our members and ensure our place in driving hospital medicine forward.

Studies show that 70% of small businesses and small non-profit organizations survive their first year, 30% survive their second year, and only 20% survive after five years. SHM will celebrate its 10th year in 2007. Congratulations and thank you. It’s you, our members, who have taken us this far. It’s you, our members, who will take us into the next 10, 20, 50 years, and beyond. We are not the same organization we were 10 years ago, and I suspect we will not be the same organization in 10 years that we are today.

Over the years I have worked and consulted in many organizations ranging from small mom-and-pops to large, multinational corporations. More often than not, despite a common desire to succeed, conflict exists within various constituencies (e.g., employees, executive management, board of directors) that leads to differing opinions on the best strategy for the company moving forward. I’m proud to say that this isn’t the case with SHM.

We have formulated a business model that uses tried-and-true corporate tools to ensure our members receive the maximum possible value in areas of the greatest impact. It encompasses both our paid and non-paid staff and volunteers to validate what matters most. Your dollars are put to good use. We concentrate on doing things that can be done and done well. If it’s a great idea but doesn’t get to the heart of what our members need or want, we won’t siphon off money and time. We receive money from our members and grantors with the intent of fulfilling a promise or mission. We try to understand what can be accomplished, and then we apply our resources to those goals, ensuring that a higher percentage of those resources are going to mission critical programs and services.

Both our members and grantors look for a strong return on their investment for the monies they send and set aside for our cause. Performance standards are necessary, not only to ensure high level delivery of services but also to ensure our organization’s fiscal responsibility. We employ a staff with many qualifications and backgrounds and coordinate our efforts further with diverse, educated, and dedicated volunteers who are experts in their areas.

Not only is our staff concerned with producing measurable results attributed to the dollars we receive, but we are also measuring mission success in numeric terms other than profit and loss, most specifically within our education and quality initiatives as well as our membership departments. Together these departments are spearheading metrics initiatives that are, for the most part, completely new to our organization but essential to our growth. We involve our staff at all levels of the organization in the pursuit of obtaining these metrics. We strive to collaboratively fulfill SHM’s objectives, and our adaptability allows us to scan the external environment and respond to the ever-changing needs of our members and grantors. Consistency of these values and the internal systems from our information services department that support problem solving, efficiency, and effectiveness at every level across our organizational boundaries help us obtain fulfilling our mission.

Communication about our direction is provided at every opportunity: staff meetings, board meetings, brown-bag lunches, and one-on-one employee discussions. Teamwork is emphasized as the primary means for accomplishing work. When decisions need to be made, all employees and volunteers are sought for counsel and advice from them, their peers, and others who might have insight about our programs. Armed with knowledge, strategic and tactical objectives that are clearly defined and pursued with greater focus, conviction, and diligence our employees embrace the change that is so evident in our fast moving organization.

Everyone in our organization understands where we are going, how we intend to get there, and how he or she fits into our organization’s strategy. The culture of our organization has shifted, but our focus on the benefits of hospital medicine has remained constant. By utilizing these strategic planning tools and techniques, we are redeveloping and revitalizing our corporate mission statement by understanding our organizations strengths, weaknesses, opportunities, threats, and actual and potential competitive advantages. This allows us to move beyond just mere expectations to actually setting the standard by which everyone will be judged.

Our employees, volunteers, members, and grantors remind us that while the business is managed on a daily basis, during our strategic planning and project implementation we focus our strategy on the vital few rather than the trivial many. This allows us to put our organization on the right track for survival and long-term growth.

As we grow, we will search harder and further for experts to help us fulfill our promise of setting SHM as the standard in hospital medicine. I encourage your feedback. Please reach me at [email protected]. You will find that I am always accessible and open to your thoughts and ideas.

Next month you will hear from Laura Allendorf, senior advisor for advocacy and government affairs.

Poitras is director of Business Operations at SHM.

Federal officials are increasingly embracing pay for performance (P4P) in an effort to promote high-quality, cost effective care in government health programs. As the Centers for Medicaid and Medicare Services (CMS) and Congress move forward to implement this concept, SHM is working to ensure that the views of hospitalists are represented in this important debate.

More than 100 P4P programs are already up and running in the private sector in an attempt to reward quality healthcare by setting different payment levels for providers based on how well they meet benchmarks of quality and efficiency. CMS is testing the feasibility of applying this concept to the Medicare program through a number of initiatives.

SHM’s Public Policy and Hospital Quality and Patient Safety committees have been involved in evaluating CMS’ Physician Voluntary Reporting Program (PVRP), launched earlier this year and widely believed to be the precursor to an eventual P4P program for physicians’ services. Under this initiative, physicians are encouraged to submit quality data on a “starter set” of 16 evidence-based measures for certain primary care, surgery, nephrology, and emergency medical services. Physicians who participate in the program receive confidential reports on their performance.

click for large version

SHM has recommended that hospitalists register their intent to report and begin reporting on relevant performance measures to the extent practicable as a way of becoming more familiar with the program. Because these initial 16 measures have only limited relevance to services billed by hospitalists, SHM is engaged in discussions with lawmakers and their staffs, CMS officials, and consensus organizations involved in developing quality measures, to expand the program’s scope.

As part of Advocacy Day on May 3, some 70 SHM members met with legislators and their staffs and conveyed SHM’s support for initiatives like the PVRP that seek to measure resource use and improve quality, to attain better value for the Medicare program. (See coverage in The Hospitalist SHM Meeting Reporter, July 2006, p. 1.) Participants also educated lawmakers on the role of hospitalists in helping their institutions meet quality reporting requirements mandated under the Medicare Modernization Act, which ties annual hospital payment updates to the submission of performance data for 10 quality measures. The participants also expressed SHM’s interest in working with CMS on demonstration projects that assess the contributions of hospital medicine programs to improved patient care and more efficient management of hospital resources.

In addition to Congress and CMS, non-governmental groups such as the National Quality Forum (NQF), the American Medical Association Physician Consortium for Performance Improvement (PCPI), and the Ambulatory Care Quality Alliance are actively engaged in providing input to CMS on the PVRP and other P4P-related initiatives. SHM has joined the PCPI, which works with medical specialty organizations to develop physician-level performance measures.

As a new member of the PCPI, SHM submitted feedback during the public comment period on perioperative care measures, the development of which was led by the American College of Surgeons, along with input from other medical specialties. SHM will also participate in two upcoming workgroups—one on emergency medicine, which will focus on treating for MI and pneumonia, and another on geriatrics, which will look at falls, urinary incontinence, and end-of-life care. At least through 2006, the PCPI is focusing on measures that fall under the CMS contract and will be included in the PVRP.

SHM is also a member of the NQF, a nonprofit organization that Congress has charged with endorsing consensus-based national standards for measurement and public reporting of healthcare performance data. NQF is seeking nominations for members of the steering committee and technical advisory panels that will oversee the work on new consensus standards for hospital care. This project, sponsored by the AHRQ, will address issues of patient safety, pediatrics, and inpatient care. SHM will submit nominations during this process and plans to be fully engaged.

To further develop its agenda on performance and quality standards in inpatient hospital care, SHM recently established a new Performance and Standards Task Force. This task force is charged with developing a coordinated approach for SHM to work with external organizations in the performance and standards and quality arena and comprises the chairs of the PPC and HQPS committees and other SHM leaders active in organizations like the JCAHO and the IHI.

P4P is here to stay. SHM is well positioned to influence the development and implementation of inpatient quality measures that may eventually become part of a Medicare P4P program for physician services. TH

Allendorf is senior advisor for Advocacy and Government Affairs at SHM. Epstein is senior advisor for Quality Standards and Compliance at SHM.

SHM: BEHIND THE SCENES

How SHM Manages Your Money

By Steven Poitras

In the past three months you have read articles from my peers, including one by Todd Von Deak concerning the great strides he is making in the membership department by ensuring that we are generating the most benefits for our members; one from Scott Johnson, who is taking us into the future with regard to information services; and from Geri Barnes, our education and quality initiatives director, who is helping drive our organizational mission of promoting excellence in the practice of hospital medicine.

This month I want to tell you about our organization, its structure, and what we are collectively doing to ensure that the dues and grants we receive are put to good use to benefit our members and ensure our place in driving hospital medicine forward.

Studies show that 70% of small businesses and small non-profit organizations survive their first year, 30% survive their second year, and only 20% survive after five years. SHM will celebrate its 10th year in 2007. Congratulations and thank you. It’s you, our members, who have taken us this far. It’s you, our members, who will take us into the next 10, 20, 50 years, and beyond. We are not the same organization we were 10 years ago, and I suspect we will not be the same organization in 10 years that we are today.

Over the years I have worked and consulted in many organizations ranging from small mom-and-pops to large, multinational corporations. More often than not, despite a common desire to succeed, conflict exists within various constituencies (e.g., employees, executive management, board of directors) that leads to differing opinions on the best strategy for the company moving forward. I’m proud to say that this isn’t the case with SHM.

We have formulated a business model that uses tried-and-true corporate tools to ensure our members receive the maximum possible value in areas of the greatest impact. It encompasses both our paid and non-paid staff and volunteers to validate what matters most. Your dollars are put to good use. We concentrate on doing things that can be done and done well. If it’s a great idea but doesn’t get to the heart of what our members need or want, we won’t siphon off money and time. We receive money from our members and grantors with the intent of fulfilling a promise or mission. We try to understand what can be accomplished, and then we apply our resources to those goals, ensuring that a higher percentage of those resources are going to mission critical programs and services.

Both our members and grantors look for a strong return on their investment for the monies they send and set aside for our cause. Performance standards are necessary, not only to ensure high level delivery of services but also to ensure our organization’s fiscal responsibility. We employ a staff with many qualifications and backgrounds and coordinate our efforts further with diverse, educated, and dedicated volunteers who are experts in their areas.

Not only is our staff concerned with producing measurable results attributed to the dollars we receive, but we are also measuring mission success in numeric terms other than profit and loss, most specifically within our education and quality initiatives as well as our membership departments. Together these departments are spearheading metrics initiatives that are, for the most part, completely new to our organization but essential to our growth. We involve our staff at all levels of the organization in the pursuit of obtaining these metrics. We strive to collaboratively fulfill SHM’s objectives, and our adaptability allows us to scan the external environment and respond to the ever-changing needs of our members and grantors. Consistency of these values and the internal systems from our information services department that support problem solving, efficiency, and effectiveness at every level across our organizational boundaries help us obtain fulfilling our mission.

Communication about our direction is provided at every opportunity: staff meetings, board meetings, brown-bag lunches, and one-on-one employee discussions. Teamwork is emphasized as the primary means for accomplishing work. When decisions need to be made, all employees and volunteers are sought for counsel and advice from them, their peers, and others who might have insight about our programs. Armed with knowledge, strategic and tactical objectives that are clearly defined and pursued with greater focus, conviction, and diligence our employees embrace the change that is so evident in our fast moving organization.

Everyone in our organization understands where we are going, how we intend to get there, and how he or she fits into our organization’s strategy. The culture of our organization has shifted, but our focus on the benefits of hospital medicine has remained constant. By utilizing these strategic planning tools and techniques, we are redeveloping and revitalizing our corporate mission statement by understanding our organizations strengths, weaknesses, opportunities, threats, and actual and potential competitive advantages. This allows us to move beyond just mere expectations to actually setting the standard by which everyone will be judged.

Our employees, volunteers, members, and grantors remind us that while the business is managed on a daily basis, during our strategic planning and project implementation we focus our strategy on the vital few rather than the trivial many. This allows us to put our organization on the right track for survival and long-term growth.

As we grow, we will search harder and further for experts to help us fulfill our promise of setting SHM as the standard in hospital medicine. I encourage your feedback. Please reach me at [email protected]. You will find that I am always accessible and open to your thoughts and ideas.

Next month you will hear from Laura Allendorf, senior advisor for advocacy and government affairs.

Poitras is director of Business Operations at SHM.

Gardens are not made by sitting in the shade.—Rudyard Kipling

For those of us who live in a climate where the vegetation dies in the winter, this is a great time of year. In the spring our plants and trees revive themselves and begin to give us color and aromas. We tend to our plants and add to our gardens with new flowers. We plant our seeds for vegetables and anxiously await the first fruit.

As I watched my garden blossoming this year, I was reminded of our Society. Perhaps, this is too poetic a comparison, but one that I think fits. No garden is pretty if it comprises all the same plant or grass or color. One of the most appealing things about a garden is its great variety. There are many variations of plants: grasses, flowers, trees, and groundcover. In a great garden, there may be many types of grass in many colors and shapes. There are flowers of various kinds. They all bloom at different times from spring to fall. Their colors range from white to the darkest blues and purples. Their fragrances are apparent in the morning or evening or at night. Some of them are phosphorescent. There are rocks and stones, water features, birds, and insects. Each part of the garden has a different role and yet together they create a peaceful and pleasing environment—a place we want to be. Without the many kinds of sites, smells, and sounds, a garden would not be interesting or pleasing to us.

Our organization is like a garden: We have many types of groups that make up the whole. For instance, we have groups of specialties. We are pediatricians. We are family medicine physicians. We are internists.

We have different professions. Our nurse practitioner and physician assistant members have a unique role. Their support of the organization and insights into patient care and care delivery give us all another perspective. In this complex age of pharmacology and polypharmacy, our pharmacy members assist us all in compiling a treatment plan for patients that helps them and does as little harm as possible. They educate us all about the many interactions and side effects of our medications.

We practice in different settings. Some of us see patients at the bedside in a community hospital. There we attempt to bring the best knowledge and skill we can to care for the individual. In addition, we bring our ideas and innovation to all the patients in our hospital by establishing new treatment plans and processes. We educate our nursing staffs and our fellow physicians. We educate our administrators about healthcare changes that can improve our community and our patients. We create liaisons with other specialists in the emergency department, the operating room, and in the ICU. Some of us practice at the bedside in a teaching setting. We care for patients with residents and medical students. We hope to bring to them a good example of empathy and care at the bedside as well as medical knowledge consistent with the best medical practice. Here, we also create liaisons with other specialists in the emergency department, the operating room, and in the ICU. By working in a multidisciplinary fashion, we hope to advance the care of all hospitalized patients.

We contribute by leading research and studies that discover new methods or new types of care. These results guide others at the bedside and in training. We have different interests. Thanks to this diversity we have individuals working on many topics to advance our specialty. Some individuals pursue public policy. They want to advance our field through the actions of the government and the national payers. The members’ focus on education has led to the core competency product, many wonderful national meetings, and active committee work. Those interested in research strive to produce a world-class journal, research opportunities, and a place for all hospitalists’ researchers. Quality and safety are important to our national healthcare. Our members have created resource rooms to disseminate information on these topics. Others, still, want to advance our field through the study of lifestyle and practice setting issues. Finally, we move toward recognition as a board certified specialty.

Regardless of how one looks at our SHM garden, we would be less of an organization without our variety and diversity. We continue to strive to meet the needs of and provide opportunities for all our members, regardless of their interests, practice setting, or discipline. We do not have a finished garden because gardens are always a work in progress, but we hope to continue to be the best place for all hospitalists to grow. TH

Dr. Gorman is the president of SHM.

Gardens are not made by sitting in the shade.—Rudyard Kipling

For those of us who live in a climate where the vegetation dies in the winter, this is a great time of year. In the spring our plants and trees revive themselves and begin to give us color and aromas. We tend to our plants and add to our gardens with new flowers. We plant our seeds for vegetables and anxiously await the first fruit.

As I watched my garden blossoming this year, I was reminded of our Society. Perhaps, this is too poetic a comparison, but one that I think fits. No garden is pretty if it comprises all the same plant or grass or color. One of the most appealing things about a garden is its great variety. There are many variations of plants: grasses, flowers, trees, and groundcover. In a great garden, there may be many types of grass in many colors and shapes. There are flowers of various kinds. They all bloom at different times from spring to fall. Their colors range from white to the darkest blues and purples. Their fragrances are apparent in the morning or evening or at night. Some of them are phosphorescent. There are rocks and stones, water features, birds, and insects. Each part of the garden has a different role and yet together they create a peaceful and pleasing environment—a place we want to be. Without the many kinds of sites, smells, and sounds, a garden would not be interesting or pleasing to us.

Our organization is like a garden: We have many types of groups that make up the whole. For instance, we have groups of specialties. We are pediatricians. We are family medicine physicians. We are internists.

We have different professions. Our nurse practitioner and physician assistant members have a unique role. Their support of the organization and insights into patient care and care delivery give us all another perspective. In this complex age of pharmacology and polypharmacy, our pharmacy members assist us all in compiling a treatment plan for patients that helps them and does as little harm as possible. They educate us all about the many interactions and side effects of our medications.

We practice in different settings. Some of us see patients at the bedside in a community hospital. There we attempt to bring the best knowledge and skill we can to care for the individual. In addition, we bring our ideas and innovation to all the patients in our hospital by establishing new treatment plans and processes. We educate our nursing staffs and our fellow physicians. We educate our administrators about healthcare changes that can improve our community and our patients. We create liaisons with other specialists in the emergency department, the operating room, and in the ICU. Some of us practice at the bedside in a teaching setting. We care for patients with residents and medical students. We hope to bring to them a good example of empathy and care at the bedside as well as medical knowledge consistent with the best medical practice. Here, we also create liaisons with other specialists in the emergency department, the operating room, and in the ICU. By working in a multidisciplinary fashion, we hope to advance the care of all hospitalized patients.

We contribute by leading research and studies that discover new methods or new types of care. These results guide others at the bedside and in training. We have different interests. Thanks to this diversity we have individuals working on many topics to advance our specialty. Some individuals pursue public policy. They want to advance our field through the actions of the government and the national payers. The members’ focus on education has led to the core competency product, many wonderful national meetings, and active committee work. Those interested in research strive to produce a world-class journal, research opportunities, and a place for all hospitalists’ researchers. Quality and safety are important to our national healthcare. Our members have created resource rooms to disseminate information on these topics. Others, still, want to advance our field through the study of lifestyle and practice setting issues. Finally, we move toward recognition as a board certified specialty.

Regardless of how one looks at our SHM garden, we would be less of an organization without our variety and diversity. We continue to strive to meet the needs of and provide opportunities for all our members, regardless of their interests, practice setting, or discipline. We do not have a finished garden because gardens are always a work in progress, but we hope to continue to be the best place for all hospitalists to grow. TH

Dr. Gorman is the president of SHM.

Gardens are not made by sitting in the shade.—Rudyard Kipling

For those of us who live in a climate where the vegetation dies in the winter, this is a great time of year. In the spring our plants and trees revive themselves and begin to give us color and aromas. We tend to our plants and add to our gardens with new flowers. We plant our seeds for vegetables and anxiously await the first fruit.

As I watched my garden blossoming this year, I was reminded of our Society. Perhaps, this is too poetic a comparison, but one that I think fits. No garden is pretty if it comprises all the same plant or grass or color. One of the most appealing things about a garden is its great variety. There are many variations of plants: grasses, flowers, trees, and groundcover. In a great garden, there may be many types of grass in many colors and shapes. There are flowers of various kinds. They all bloom at different times from spring to fall. Their colors range from white to the darkest blues and purples. Their fragrances are apparent in the morning or evening or at night. Some of them are phosphorescent. There are rocks and stones, water features, birds, and insects. Each part of the garden has a different role and yet together they create a peaceful and pleasing environment—a place we want to be. Without the many kinds of sites, smells, and sounds, a garden would not be interesting or pleasing to us.

Our organization is like a garden: We have many types of groups that make up the whole. For instance, we have groups of specialties. We are pediatricians. We are family medicine physicians. We are internists.

We have different professions. Our nurse practitioner and physician assistant members have a unique role. Their support of the organization and insights into patient care and care delivery give us all another perspective. In this complex age of pharmacology and polypharmacy, our pharmacy members assist us all in compiling a treatment plan for patients that helps them and does as little harm as possible. They educate us all about the many interactions and side effects of our medications.

We practice in different settings. Some of us see patients at the bedside in a community hospital. There we attempt to bring the best knowledge and skill we can to care for the individual. In addition, we bring our ideas and innovation to all the patients in our hospital by establishing new treatment plans and processes. We educate our nursing staffs and our fellow physicians. We educate our administrators about healthcare changes that can improve our community and our patients. We create liaisons with other specialists in the emergency department, the operating room, and in the ICU. Some of us practice at the bedside in a teaching setting. We care for patients with residents and medical students. We hope to bring to them a good example of empathy and care at the bedside as well as medical knowledge consistent with the best medical practice. Here, we also create liaisons with other specialists in the emergency department, the operating room, and in the ICU. By working in a multidisciplinary fashion, we hope to advance the care of all hospitalized patients.

We contribute by leading research and studies that discover new methods or new types of care. These results guide others at the bedside and in training. We have different interests. Thanks to this diversity we have individuals working on many topics to advance our specialty. Some individuals pursue public policy. They want to advance our field through the actions of the government and the national payers. The members’ focus on education has led to the core competency product, many wonderful national meetings, and active committee work. Those interested in research strive to produce a world-class journal, research opportunities, and a place for all hospitalists’ researchers. Quality and safety are important to our national healthcare. Our members have created resource rooms to disseminate information on these topics. Others, still, want to advance our field through the study of lifestyle and practice setting issues. Finally, we move toward recognition as a board certified specialty.

Regardless of how one looks at our SHM garden, we would be less of an organization without our variety and diversity. We continue to strive to meet the needs of and provide opportunities for all our members, regardless of their interests, practice setting, or discipline. We do not have a finished garden because gardens are always a work in progress, but we hope to continue to be the best place for all hospitalists to grow. TH

Dr. Gorman is the president of SHM.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.

Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.

Top Considerations

Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”

After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”

The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.

“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.

Biggest Challenges

One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.

These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.

Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.

In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.

Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.

Tailor the Summary

Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.

“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”

The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.

“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.

We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.

—Edward J. Merrens, MD

Back to Long-Term Care

The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:

1. Age 80 and older;
2. A history of depression;
3. Multiple chronic diseases;
4. Moderate-to-severe functional impairment;
5. Noncompliance with therapy;
6. Inadequate social supports;
7. Multiple hospitalizations in the previous six months;
8. Hospitalization in the last 30 days; and
9. Fair or poor self-rating of health.4

Patients who return to long-term care, therefore, need careful transfer of information.

Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).

At and After Discharge: Communicate with Patients and Families

Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5

Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.

The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.

Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8

Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.

Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9

Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.

Test Results and Follow-Up Studies

Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.

Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10

When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.

Follow-up Contact with Patients

Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.

Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13

In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.

Adverse Drug Events and Other Medication Issues

Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15

Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.

Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.

Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.

Top Considerations

Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”

After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”

The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.

“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.

Biggest Challenges

One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.

These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.

Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.

In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.

Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.

Tailor the Summary

Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.

“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”

The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.

“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.

We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.

—Edward J. Merrens, MD

Back to Long-Term Care

The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:

1. Age 80 and older;
2. A history of depression;
3. Multiple chronic diseases;
4. Moderate-to-severe functional impairment;
5. Noncompliance with therapy;
6. Inadequate social supports;
7. Multiple hospitalizations in the previous six months;
8. Hospitalization in the last 30 days; and
9. Fair or poor self-rating of health.4

Patients who return to long-term care, therefore, need careful transfer of information.

Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).

At and After Discharge: Communicate with Patients and Families

Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5

Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.

The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.

Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8

Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.

Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9

Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.

Test Results and Follow-Up Studies

Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.

Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10

When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.

Follow-up Contact with Patients

Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.

Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13

In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.

Adverse Drug Events and Other Medication Issues

Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15

Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.

Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.

Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.

Top Considerations

Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”

After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”

The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.

“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.

Biggest Challenges

One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.

These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.

Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.

In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.

Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.

Tailor the Summary

Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.

“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”

The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.

“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.

We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.

—Edward J. Merrens, MD

Back to Long-Term Care

The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:

1. Age 80 and older;
2. A history of depression;
3. Multiple chronic diseases;
4. Moderate-to-severe functional impairment;
5. Noncompliance with therapy;
6. Inadequate social supports;
7. Multiple hospitalizations in the previous six months;
8. Hospitalization in the last 30 days; and
9. Fair or poor self-rating of health.4

Patients who return to long-term care, therefore, need careful transfer of information.

Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).

At and After Discharge: Communicate with Patients and Families

Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5

Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.

The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.

Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8

Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.

Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9

Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.

Test Results and Follow-Up Studies

Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.

Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10

When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.

Follow-up Contact with Patients

Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.

Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13

In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.

Adverse Drug Events and Other Medication Issues

Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15

Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented.

Massachusetts’ lawmakers garnered huge headlines across the nation in April when the Democratic-dominated state legislature passed a health insurance reform bill nearly unanimously, and Republican Governor Mitt Romney signed the bill into law. This summer, health policy experts are hard at work implementing the first of many mandated stages of the legislation. Other states will watch Massachusetts in the next year as administrators hammer out details of the much-heralded bipartisan statute. Much remains to be done, however, and effects of the statute on patients, hospitals, and physicians remain unclear.

The hope is that the state can ensure nearly universal health insurance coverage for its estimated 500,000 citizens who currently have none. The Massachusetts statute aims to accomplish this feat by offering subsidized insurance coverage to those earning up to 300% of the federal poverty level (facilitated by a Medicaid waiver now being finalized between the state and CMS); assessing $295 per employee from businesses with 11 or more employees who do not provide coverage; and requiring purchase of affordable individual insurance products by those to whom such products are available.

Can the complex, market-driven compromise work? If all staged implementations go into effect as planned, will they be sustainable? Once in place, how might these reforms play out for the practice of hospital medicine? The Hospitalist recently solicited opinions from several hospitalists, physicians, a network president, and health policy experts to get some idea of what the future may hold for healthcare delivery in Massachusetts.

Key Features of the Legislation

As the number of uninsured Americans continues to grow, and reform at the federal level has stalled, many states have been working on their own plans to increase access to insurance and healthcare. The linchpin of individuals’ and businesses’ shared responsibility, health policy experts say, was key to the bipartisan support shown for the Massachusetts insurance reform bill. As of July 1, 2007, every citizen over 18 will be required to obtain health insurance. Businesses with 11 or more employees must pay $295 per employee if they do not offer coverage. (This provision was vetoed by Governor Romney when he signed the bill, but it was subsequently overridden by the legislature.)

The legislation—hundreds of pages long—stipulates an approximate two-year timeline for implementing all phases of the plan, and includes state tax penalties for individuals who don’t comply with the requirement to obtain insurance. The law also creates a state authority, The Commonwealth Health Insurance Connector, to set eligibility standards for subsidized policies, expand Medicaid enrollment, determine affordability guidelines, and approve of plans submitted by private insurers to be offered to consumers. It is anticipated that The Connector (its nickname) will act as a clearinghouse, linking individuals and small businesses with choices of affordable health plans paid for with pretax dollars.

Some of the features lauded by most—even critics—include expansion of Medicaid enrollment; policies with no to low premiums and no deductibles, on a sliding scale, for individuals and families earning up to 300% of the federal poverty line ($29,400 for individuals and $60,000 for families in the contiguous 48 states); and portability of the policies. In addition, young adults can remain covered through their parents’ policies until they become independent or reach age 25. Other specially designed low cost, limited coverage plans will be offered to young adults between ages 19 and 26.

In the press, the statute has been touted as providing “universal care,” but critics doubt that the coverage will be truly universal. For instance, they claim, based on U.S. Census data, that the number of uninsured in Massachusetts is closer to 714,000—not the 500,000 that resulted from bilingual telephone surveys used by those who drafted the bill. Those who espouse a single-payer solution to the insurance crisis, such as Physicians for a National Health Policy and Mass-Care (the statewide coalition of organizations that back single-payer healthcare), argue that mandating purchase of individual plans will shut many working families out of the market. Even administrators and physicians interviewed for this article admit that to generate affordable policies, insurers may have to limit networks and benefits. And increasing the number of insured citizens may have no effect on the rising tide of healthcare delivery costs. With so many unknowns, and a complicated administrative system to initiate, the task of fulfilling the statute’s mandate is daunting.

Where It Is Now

Reached in mid-July between meetings, Jon M. Kingsdale, PhD, newly appointed executive director of the Commonwealth Health Insurance Connector Authority, reported that his board had met five times since June 7. Included in its busy schedule: generating a plan of operations and a budget and hiring staff. The Connector also met its first legislative deadline, which was to develop and issue regulations and criteria by July 1, 2006, for contracting with health plans for the Commonwealth Care Health Insurance Program, or C-CHIP. This is the state-subsidized health plan for people earning up to 300% of the federal poverty line that will begin on October 1, 2006. Key features of C-CHIP and other components of the Massachusetts health reform include no premiums for those who earn less than 100% of the federal poverty line, increased coverage for children, and increased Medicaid reimbursement rates for providers (a good thing for hospitals). Premiums for those earning 100%-300% of the federal poverty line will be set according to a sliding scale, but none of the C-CHIP plans include deductibles. Funding for this plan will come from federal and state matching Medicaid funds made possible by a waiver currently being negotiated between Massachusetts and CMS. (Formal approval had not yet been granted by CMS as of July 21.)

As to the insurance products for those earning above 300% of the federal poverty level, Dr. Kingsdale says The Connector board will address affordability criteria once C-CHIP deadlines have been met. The legislation calls for The Connector to provide its seal of approval for plans that are offered and make determinations about continuing or withdrawing approval. After two years, the agency will formally evaluate the program and make recommendations for changes.

Reactions to the Plan

Joseph Li, MD, assistant professor of medicine at Harvard Medical School and director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston, admits that his excitement about the insurance statute is somewhat tempered. His personal opinion, which does not reflect his group’s or hospital’s opinion—is that he will “believe it when it’s truly enacted.”

Massachusetts has passed healthcare care reform bills in the past: Witness the 1988 legislation under Governor Michael Dukakis that was later repealed. Nevertheless, Dr. Li says, “I’m glad to see it happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.”

Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.

Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.

What’s “Affordable?”

The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”

People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.

“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].

“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”

Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.

Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”

Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”

Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”

I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.

—Joseph Li, MD

Some Likely Effects

For his hospitalist group at University of Massachusetts (UMass) Memorial Medical Center in Worcester, the new legislation “will not represent any new change in our mission or change in the composition of our typical patient panels,” says Glenn Allison, MD, chief of the Division of Hospital Medicine.

Hospitalists, in general, are accustomed to and adept at caring for unassigned patients included in the uncompensated pool, he notes, and at UMass, caring for these patients is a major mission of the hospital. Dr. Allison is hopeful that the legislation holds promise for bringing many previously marginalized and uninsured people into the healthcare system.

Thomas H. Lee, MD, MPH, network president of Partners HealthCare System, Inc, Boston, believes everyone in Massachusetts wants the healthcare reform to work. All stakeholders must “face reality,” he says, and realize that lowering the cost of healthcare is imperative. “It’s clear that the whole healthcare system must become more efficient. The imperative for that was present before this legislation was passed, and I’m not sure the pressures for that imperative are going to change qualitatively.”

One change Dr. Lee does foresee due to the legislation’s dependence on market reforms is that resulting insurance products will “spend a lot less money on patients than existing ones do. There are going to be a variety of pressures on doctors and hospitals to either be much more efficient or take less money for what they do,” he says. “Given that choice, most of us would rather become more efficient.”

Another consequence of affordable insurance products may be a narrowing of provider networks. And a narrow network product, says Sylvia C.W. McKean, MD, FACP, medical director of the BWH/Faulkner Hospitalist Service at Brigham and Women’s Hospital in Boston, “might result in a reduced number of patients going to tertiary care hospitals, which currently care for a large number of indigent patients.”

Even though standards of affordability and details of insurance products have yet to be generated by The Connector and insurers, Dr. Lee also believes that narrowing of benefits and networks will be one likely consequence of the legislation. This will entail some difficult choices about the range of services hospitals and physicians can offer. But, he says, “I think it’s worth doing painful, difficult stuff, and making painful, ugly choices in order for everyone to have necessary catastrophic care and to have access to basic preventive care. We should be willing to live with some of that ugly stuff because it will, in Massachusetts, at least, give us a chance of preventing the need for even uglier outcomes, which is, 10% of our population not having any coverage at all.”

Dr. Lee believes that hospitalists will be critical to the success of hospital efficiency. “To the extent that institutions can use hospitalists and other systems to become much more efficient and reduce readmissions, it’s going to mitigate the need for the narrowing of benefits and networks,” he says.

Now that these [formerly uninsured or underinsured] people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources.

—Glenn Allison, MD

Upshot for Hospitalists

Unknowns about the workability of and funding for the legislation abound. It’s not clear whether shifting costs to individuals (by mandating they purchase private insurance) and employers (via the $295 per employee fee) can bridge current deficits in compensation and care. Dr. Lee points out that “it’s still an open question of whether there is going to be enough money. But clearly, there are going to be insurance products that spend a lot less money on patients than existing ones do.”

Dr. Li does not believe these funding questions will affect the bottom line for his hospitalist group because their compensation is based on productivity, as measured by relative value units (RVUs).

The next 10 months or so leading up to the July 1, 2007, deadline for purchase of individual health insurance policies will be revealing for consumers and physicians alike. Although the devil will be in the details, Dr. Lee notes, “The big picture is not uncertain. We know there is going to be more transparency, more data, on quality and efficiency.”

That means that hospitals’ delivery of care will endure more scrutiny, and that pay for performance will become commonplace.

The influx of patients into the healthcare system, which legislators hope will be a consequence of greater access to care, will necessitate some consciousness-raising for hospitalists, Dr. Allison maintains. While hospitalists already work closely with other providers on the multidisciplinary team (social workers, case managers, and primary care physicians), they will have to strengthen those collaborations to ensure that patients don’t fall through the cracks. Community outreach may become part of the hospitalists’ job description.

For example, he explains, many preventive or follow-up services that are now being performed in the hospital because patients have no primary care physicians can now be referred to outpatient sites. “Now that these people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources,” he says.

Steering patients to community-based preventive services, such as early cardiac and cancer screenings, will fall to hospitalists, who will be “on the frontlines seeing these patients and referring them appropriately as they leave the hospital,” says Dr. Allison. Hospitalists and all providers will also be evaluated by how well they deliver culturally competent care—another mandate of the statute. To steer through these changes, hospitalists must become much more conscious, he says, of costs, communications, referrals, and resources. “That, as far as I can see, has not been a major emphasis of hospitalist literature or debate.”

A Role to Play

Dr. McKean and others contend that by virtue of their skill set and core mission, hospitalists will have much to contribute toward moderating the costs of healthcare. “The good news for hospitalists,” says Turnbull, “is that if we’re successful in providing health coverage to many people who are now uninsured and if that coverage is adequate there should be more people receiving primary and preventive care and services. This should prevent them from needing to go to the hospital in the first place. We should also be able to create more rational systems of care for people, so that when patients are in the hospital, they need to be there, and they can take full advantage of the talents and contributions that hospitalists make.”

Dr. Kingsdale agrees with the assessment that hospitalists will have a potentially significant role to play in improving the delivery, efficiency, and quality of care, as well as reducing medical errors. He hopes the new insurance products generated by companies will include financial incentives for hospitals and other providers who will be doing “the difficult work of changing their systems of care.”

“The healthcare system really has to improve,” asserts Dr. Lee. “In our organization, we say that we need both an industrial revolution and a cultural revolution, where we develop and use systems that reduce errors. There are electronic records and other industrial systems, and then there are human-ware systems, like hospitalists and disease management programs.”

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented. The April legislation “elevates the stakes for delivering effective, quality inpatient care,” says Dr. Allison. “I don’t want to over-inflate our importance, but I do think in a system where so many of our healthcare dollars are expended on the inpatient side, we’ve got to be extremely conscious of what we do.” This may mean shifting hospitalists’ implicit skills into the explicit realm, he says: “For instance, everyone talks about guidelines and how helpful they are, but we don’t do a good enough job when it comes to using them. We need to do better with vaccination, with discharge instructions, and with communicating and coordinating care.

“I think the care coordination piece is going to be the key to success,” concludes Dr. Allison. “I think we need to take what we do now, but do more of it, and do a better job of it. That is something that will make a tough job even tougher. But I think if we fail in this, the whole effort may collapse.” TH

Gretchen Henkel is coauthor of Marketing Your Clinical Practice—Ethically, Effectively, Economically.

Resources

1. Altman SH, Doonan M. “Can Massachusetts lead the way in health care reform?” N Engl J Med. 2006 May;354(20):2093-2095.
2. Steinbrook R. Health care reform in Massachusetts—a work in progress. N Engl J Med. 2006 May;354(20): 2095-2098.
3. The 184th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006, an act providing access to affordable, quality, accountable health care. Available at: www.mass.gov/legis/summary.pdf). Last accessed June 12, 2006.
4. Johnston PW, Turnbull NC. A bold insurance experiment. The Boston Globe. April 16, 2006. Available at: www.boston.com. Last accessed June 26, 2006.
5. McCormick D, Himmelstein DU, Woolhandler S, et al. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004 Feb 9;164(3):300-304.
6. “Massachusetts Health Reform Bill: A False Promise of Universal Coverage.” Statement by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD. Available at www.pnhp.org/news/2006/april/massachusetts_health.php. Last accessed June 26, 2006.

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented.

Massachusetts’ lawmakers garnered huge headlines across the nation in April when the Democratic-dominated state legislature passed a health insurance reform bill nearly unanimously, and Republican Governor Mitt Romney signed the bill into law. This summer, health policy experts are hard at work implementing the first of many mandated stages of the legislation. Other states will watch Massachusetts in the next year as administrators hammer out details of the much-heralded bipartisan statute. Much remains to be done, however, and effects of the statute on patients, hospitals, and physicians remain unclear.

The hope is that the state can ensure nearly universal health insurance coverage for its estimated 500,000 citizens who currently have none. The Massachusetts statute aims to accomplish this feat by offering subsidized insurance coverage to those earning up to 300% of the federal poverty level (facilitated by a Medicaid waiver now being finalized between the state and CMS); assessing $295 per employee from businesses with 11 or more employees who do not provide coverage; and requiring purchase of affordable individual insurance products by those to whom such products are available.

Can the complex, market-driven compromise work? If all staged implementations go into effect as planned, will they be sustainable? Once in place, how might these reforms play out for the practice of hospital medicine? The Hospitalist recently solicited opinions from several hospitalists, physicians, a network president, and health policy experts to get some idea of what the future may hold for healthcare delivery in Massachusetts.

Key Features of the Legislation

As the number of uninsured Americans continues to grow, and reform at the federal level has stalled, many states have been working on their own plans to increase access to insurance and healthcare. The linchpin of individuals’ and businesses’ shared responsibility, health policy experts say, was key to the bipartisan support shown for the Massachusetts insurance reform bill. As of July 1, 2007, every citizen over 18 will be required to obtain health insurance. Businesses with 11 or more employees must pay $295 per employee if they do not offer coverage. (This provision was vetoed by Governor Romney when he signed the bill, but it was subsequently overridden by the legislature.)

The legislation—hundreds of pages long—stipulates an approximate two-year timeline for implementing all phases of the plan, and includes state tax penalties for individuals who don’t comply with the requirement to obtain insurance. The law also creates a state authority, The Commonwealth Health Insurance Connector, to set eligibility standards for subsidized policies, expand Medicaid enrollment, determine affordability guidelines, and approve of plans submitted by private insurers to be offered to consumers. It is anticipated that The Connector (its nickname) will act as a clearinghouse, linking individuals and small businesses with choices of affordable health plans paid for with pretax dollars.

Some of the features lauded by most—even critics—include expansion of Medicaid enrollment; policies with no to low premiums and no deductibles, on a sliding scale, for individuals and families earning up to 300% of the federal poverty line ($29,400 for individuals and $60,000 for families in the contiguous 48 states); and portability of the policies. In addition, young adults can remain covered through their parents’ policies until they become independent or reach age 25. Other specially designed low cost, limited coverage plans will be offered to young adults between ages 19 and 26.

In the press, the statute has been touted as providing “universal care,” but critics doubt that the coverage will be truly universal. For instance, they claim, based on U.S. Census data, that the number of uninsured in Massachusetts is closer to 714,000—not the 500,000 that resulted from bilingual telephone surveys used by those who drafted the bill. Those who espouse a single-payer solution to the insurance crisis, such as Physicians for a National Health Policy and Mass-Care (the statewide coalition of organizations that back single-payer healthcare), argue that mandating purchase of individual plans will shut many working families out of the market. Even administrators and physicians interviewed for this article admit that to generate affordable policies, insurers may have to limit networks and benefits. And increasing the number of insured citizens may have no effect on the rising tide of healthcare delivery costs. With so many unknowns, and a complicated administrative system to initiate, the task of fulfilling the statute’s mandate is daunting.

Where It Is Now

Reached in mid-July between meetings, Jon M. Kingsdale, PhD, newly appointed executive director of the Commonwealth Health Insurance Connector Authority, reported that his board had met five times since June 7. Included in its busy schedule: generating a plan of operations and a budget and hiring staff. The Connector also met its first legislative deadline, which was to develop and issue regulations and criteria by July 1, 2006, for contracting with health plans for the Commonwealth Care Health Insurance Program, or C-CHIP. This is the state-subsidized health plan for people earning up to 300% of the federal poverty line that will begin on October 1, 2006. Key features of C-CHIP and other components of the Massachusetts health reform include no premiums for those who earn less than 100% of the federal poverty line, increased coverage for children, and increased Medicaid reimbursement rates for providers (a good thing for hospitals). Premiums for those earning 100%-300% of the federal poverty line will be set according to a sliding scale, but none of the C-CHIP plans include deductibles. Funding for this plan will come from federal and state matching Medicaid funds made possible by a waiver currently being negotiated between Massachusetts and CMS. (Formal approval had not yet been granted by CMS as of July 21.)

As to the insurance products for those earning above 300% of the federal poverty level, Dr. Kingsdale says The Connector board will address affordability criteria once C-CHIP deadlines have been met. The legislation calls for The Connector to provide its seal of approval for plans that are offered and make determinations about continuing or withdrawing approval. After two years, the agency will formally evaluate the program and make recommendations for changes.

Reactions to the Plan

Joseph Li, MD, assistant professor of medicine at Harvard Medical School and director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston, admits that his excitement about the insurance statute is somewhat tempered. His personal opinion, which does not reflect his group’s or hospital’s opinion—is that he will “believe it when it’s truly enacted.”

Massachusetts has passed healthcare care reform bills in the past: Witness the 1988 legislation under Governor Michael Dukakis that was later repealed. Nevertheless, Dr. Li says, “I’m glad to see it happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.”

Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.

Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.

What’s “Affordable?”

The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”

People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.

“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].

“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”

Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.

Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”

Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”

Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”

I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.

—Joseph Li, MD

Some Likely Effects

For his hospitalist group at University of Massachusetts (UMass) Memorial Medical Center in Worcester, the new legislation “will not represent any new change in our mission or change in the composition of our typical patient panels,” says Glenn Allison, MD, chief of the Division of Hospital Medicine.

Hospitalists, in general, are accustomed to and adept at caring for unassigned patients included in the uncompensated pool, he notes, and at UMass, caring for these patients is a major mission of the hospital. Dr. Allison is hopeful that the legislation holds promise for bringing many previously marginalized and uninsured people into the healthcare system.

Thomas H. Lee, MD, MPH, network president of Partners HealthCare System, Inc, Boston, believes everyone in Massachusetts wants the healthcare reform to work. All stakeholders must “face reality,” he says, and realize that lowering the cost of healthcare is imperative. “It’s clear that the whole healthcare system must become more efficient. The imperative for that was present before this legislation was passed, and I’m not sure the pressures for that imperative are going to change qualitatively.”

One change Dr. Lee does foresee due to the legislation’s dependence on market reforms is that resulting insurance products will “spend a lot less money on patients than existing ones do. There are going to be a variety of pressures on doctors and hospitals to either be much more efficient or take less money for what they do,” he says. “Given that choice, most of us would rather become more efficient.”

Another consequence of affordable insurance products may be a narrowing of provider networks. And a narrow network product, says Sylvia C.W. McKean, MD, FACP, medical director of the BWH/Faulkner Hospitalist Service at Brigham and Women’s Hospital in Boston, “might result in a reduced number of patients going to tertiary care hospitals, which currently care for a large number of indigent patients.”

Even though standards of affordability and details of insurance products have yet to be generated by The Connector and insurers, Dr. Lee also believes that narrowing of benefits and networks will be one likely consequence of the legislation. This will entail some difficult choices about the range of services hospitals and physicians can offer. But, he says, “I think it’s worth doing painful, difficult stuff, and making painful, ugly choices in order for everyone to have necessary catastrophic care and to have access to basic preventive care. We should be willing to live with some of that ugly stuff because it will, in Massachusetts, at least, give us a chance of preventing the need for even uglier outcomes, which is, 10% of our population not having any coverage at all.”

Dr. Lee believes that hospitalists will be critical to the success of hospital efficiency. “To the extent that institutions can use hospitalists and other systems to become much more efficient and reduce readmissions, it’s going to mitigate the need for the narrowing of benefits and networks,” he says.

Now that these [formerly uninsured or underinsured] people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources.

—Glenn Allison, MD

Upshot for Hospitalists

Unknowns about the workability of and funding for the legislation abound. It’s not clear whether shifting costs to individuals (by mandating they purchase private insurance) and employers (via the $295 per employee fee) can bridge current deficits in compensation and care. Dr. Lee points out that “it’s still an open question of whether there is going to be enough money. But clearly, there are going to be insurance products that spend a lot less money on patients than existing ones do.”

Dr. Li does not believe these funding questions will affect the bottom line for his hospitalist group because their compensation is based on productivity, as measured by relative value units (RVUs).

The next 10 months or so leading up to the July 1, 2007, deadline for purchase of individual health insurance policies will be revealing for consumers and physicians alike. Although the devil will be in the details, Dr. Lee notes, “The big picture is not uncertain. We know there is going to be more transparency, more data, on quality and efficiency.”

That means that hospitals’ delivery of care will endure more scrutiny, and that pay for performance will become commonplace.

The influx of patients into the healthcare system, which legislators hope will be a consequence of greater access to care, will necessitate some consciousness-raising for hospitalists, Dr. Allison maintains. While hospitalists already work closely with other providers on the multidisciplinary team (social workers, case managers, and primary care physicians), they will have to strengthen those collaborations to ensure that patients don’t fall through the cracks. Community outreach may become part of the hospitalists’ job description.

For example, he explains, many preventive or follow-up services that are now being performed in the hospital because patients have no primary care physicians can now be referred to outpatient sites. “Now that these people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources,” he says.

Steering patients to community-based preventive services, such as early cardiac and cancer screenings, will fall to hospitalists, who will be “on the frontlines seeing these patients and referring them appropriately as they leave the hospital,” says Dr. Allison. Hospitalists and all providers will also be evaluated by how well they deliver culturally competent care—another mandate of the statute. To steer through these changes, hospitalists must become much more conscious, he says, of costs, communications, referrals, and resources. “That, as far as I can see, has not been a major emphasis of hospitalist literature or debate.”

A Role to Play

Dr. McKean and others contend that by virtue of their skill set and core mission, hospitalists will have much to contribute toward moderating the costs of healthcare. “The good news for hospitalists,” says Turnbull, “is that if we’re successful in providing health coverage to many people who are now uninsured and if that coverage is adequate there should be more people receiving primary and preventive care and services. This should prevent them from needing to go to the hospital in the first place. We should also be able to create more rational systems of care for people, so that when patients are in the hospital, they need to be there, and they can take full advantage of the talents and contributions that hospitalists make.”

Dr. Kingsdale agrees with the assessment that hospitalists will have a potentially significant role to play in improving the delivery, efficiency, and quality of care, as well as reducing medical errors. He hopes the new insurance products generated by companies will include financial incentives for hospitals and other providers who will be doing “the difficult work of changing their systems of care.”

“The healthcare system really has to improve,” asserts Dr. Lee. “In our organization, we say that we need both an industrial revolution and a cultural revolution, where we develop and use systems that reduce errors. There are electronic records and other industrial systems, and then there are human-ware systems, like hospitalists and disease management programs.”

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented. The April legislation “elevates the stakes for delivering effective, quality inpatient care,” says Dr. Allison. “I don’t want to over-inflate our importance, but I do think in a system where so many of our healthcare dollars are expended on the inpatient side, we’ve got to be extremely conscious of what we do.” This may mean shifting hospitalists’ implicit skills into the explicit realm, he says: “For instance, everyone talks about guidelines and how helpful they are, but we don’t do a good enough job when it comes to using them. We need to do better with vaccination, with discharge instructions, and with communicating and coordinating care.

“I think the care coordination piece is going to be the key to success,” concludes Dr. Allison. “I think we need to take what we do now, but do more of it, and do a better job of it. That is something that will make a tough job even tougher. But I think if we fail in this, the whole effort may collapse.” TH

Gretchen Henkel is coauthor of Marketing Your Clinical Practice—Ethically, Effectively, Economically.

Resources

1. Altman SH, Doonan M. “Can Massachusetts lead the way in health care reform?” N Engl J Med. 2006 May;354(20):2093-2095.
2. Steinbrook R. Health care reform in Massachusetts—a work in progress. N Engl J Med. 2006 May;354(20): 2095-2098.
3. The 184th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006, an act providing access to affordable, quality, accountable health care. Available at: www.mass.gov/legis/summary.pdf). Last accessed June 12, 2006.
4. Johnston PW, Turnbull NC. A bold insurance experiment. The Boston Globe. April 16, 2006. Available at: www.boston.com. Last accessed June 26, 2006.
5. McCormick D, Himmelstein DU, Woolhandler S, et al. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004 Feb 9;164(3):300-304.
6. “Massachusetts Health Reform Bill: A False Promise of Universal Coverage.” Statement by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD. Available at www.pnhp.org/news/2006/april/massachusetts_health.php. Last accessed June 26, 2006.

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented.

Massachusetts’ lawmakers garnered huge headlines across the nation in April when the Democratic-dominated state legislature passed a health insurance reform bill nearly unanimously, and Republican Governor Mitt Romney signed the bill into law. This summer, health policy experts are hard at work implementing the first of many mandated stages of the legislation. Other states will watch Massachusetts in the next year as administrators hammer out details of the much-heralded bipartisan statute. Much remains to be done, however, and effects of the statute on patients, hospitals, and physicians remain unclear.

The hope is that the state can ensure nearly universal health insurance coverage for its estimated 500,000 citizens who currently have none. The Massachusetts statute aims to accomplish this feat by offering subsidized insurance coverage to those earning up to 300% of the federal poverty level (facilitated by a Medicaid waiver now being finalized between the state and CMS); assessing $295 per employee from businesses with 11 or more employees who do not provide coverage; and requiring purchase of affordable individual insurance products by those to whom such products are available.

Can the complex, market-driven compromise work? If all staged implementations go into effect as planned, will they be sustainable? Once in place, how might these reforms play out for the practice of hospital medicine? The Hospitalist recently solicited opinions from several hospitalists, physicians, a network president, and health policy experts to get some idea of what the future may hold for healthcare delivery in Massachusetts.

Key Features of the Legislation

As the number of uninsured Americans continues to grow, and reform at the federal level has stalled, many states have been working on their own plans to increase access to insurance and healthcare. The linchpin of individuals’ and businesses’ shared responsibility, health policy experts say, was key to the bipartisan support shown for the Massachusetts insurance reform bill. As of July 1, 2007, every citizen over 18 will be required to obtain health insurance. Businesses with 11 or more employees must pay $295 per employee if they do not offer coverage. (This provision was vetoed by Governor Romney when he signed the bill, but it was subsequently overridden by the legislature.)

The legislation—hundreds of pages long—stipulates an approximate two-year timeline for implementing all phases of the plan, and includes state tax penalties for individuals who don’t comply with the requirement to obtain insurance. The law also creates a state authority, The Commonwealth Health Insurance Connector, to set eligibility standards for subsidized policies, expand Medicaid enrollment, determine affordability guidelines, and approve of plans submitted by private insurers to be offered to consumers. It is anticipated that The Connector (its nickname) will act as a clearinghouse, linking individuals and small businesses with choices of affordable health plans paid for with pretax dollars.

Some of the features lauded by most—even critics—include expansion of Medicaid enrollment; policies with no to low premiums and no deductibles, on a sliding scale, for individuals and families earning up to 300% of the federal poverty line ($29,400 for individuals and $60,000 for families in the contiguous 48 states); and portability of the policies. In addition, young adults can remain covered through their parents’ policies until they become independent or reach age 25. Other specially designed low cost, limited coverage plans will be offered to young adults between ages 19 and 26.

In the press, the statute has been touted as providing “universal care,” but critics doubt that the coverage will be truly universal. For instance, they claim, based on U.S. Census data, that the number of uninsured in Massachusetts is closer to 714,000—not the 500,000 that resulted from bilingual telephone surveys used by those who drafted the bill. Those who espouse a single-payer solution to the insurance crisis, such as Physicians for a National Health Policy and Mass-Care (the statewide coalition of organizations that back single-payer healthcare), argue that mandating purchase of individual plans will shut many working families out of the market. Even administrators and physicians interviewed for this article admit that to generate affordable policies, insurers may have to limit networks and benefits. And increasing the number of insured citizens may have no effect on the rising tide of healthcare delivery costs. With so many unknowns, and a complicated administrative system to initiate, the task of fulfilling the statute’s mandate is daunting.

Where It Is Now

Reached in mid-July between meetings, Jon M. Kingsdale, PhD, newly appointed executive director of the Commonwealth Health Insurance Connector Authority, reported that his board had met five times since June 7. Included in its busy schedule: generating a plan of operations and a budget and hiring staff. The Connector also met its first legislative deadline, which was to develop and issue regulations and criteria by July 1, 2006, for contracting with health plans for the Commonwealth Care Health Insurance Program, or C-CHIP. This is the state-subsidized health plan for people earning up to 300% of the federal poverty line that will begin on October 1, 2006. Key features of C-CHIP and other components of the Massachusetts health reform include no premiums for those who earn less than 100% of the federal poverty line, increased coverage for children, and increased Medicaid reimbursement rates for providers (a good thing for hospitals). Premiums for those earning 100%-300% of the federal poverty line will be set according to a sliding scale, but none of the C-CHIP plans include deductibles. Funding for this plan will come from federal and state matching Medicaid funds made possible by a waiver currently being negotiated between Massachusetts and CMS. (Formal approval had not yet been granted by CMS as of July 21.)

As to the insurance products for those earning above 300% of the federal poverty level, Dr. Kingsdale says The Connector board will address affordability criteria once C-CHIP deadlines have been met. The legislation calls for The Connector to provide its seal of approval for plans that are offered and make determinations about continuing or withdrawing approval. After two years, the agency will formally evaluate the program and make recommendations for changes.

Reactions to the Plan

Joseph Li, MD, assistant professor of medicine at Harvard Medical School and director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston, admits that his excitement about the insurance statute is somewhat tempered. His personal opinion, which does not reflect his group’s or hospital’s opinion—is that he will “believe it when it’s truly enacted.”

Massachusetts has passed healthcare care reform bills in the past: Witness the 1988 legislation under Governor Michael Dukakis that was later repealed. Nevertheless, Dr. Li says, “I’m glad to see it happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.”

Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.

Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.

What’s “Affordable?”

The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”

People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.

“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].

“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”

Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.

Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”

Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”

Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”

I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.

—Joseph Li, MD

Some Likely Effects

For his hospitalist group at University of Massachusetts (UMass) Memorial Medical Center in Worcester, the new legislation “will not represent any new change in our mission or change in the composition of our typical patient panels,” says Glenn Allison, MD, chief of the Division of Hospital Medicine.

Hospitalists, in general, are accustomed to and adept at caring for unassigned patients included in the uncompensated pool, he notes, and at UMass, caring for these patients is a major mission of the hospital. Dr. Allison is hopeful that the legislation holds promise for bringing many previously marginalized and uninsured people into the healthcare system.

Thomas H. Lee, MD, MPH, network president of Partners HealthCare System, Inc, Boston, believes everyone in Massachusetts wants the healthcare reform to work. All stakeholders must “face reality,” he says, and realize that lowering the cost of healthcare is imperative. “It’s clear that the whole healthcare system must become more efficient. The imperative for that was present before this legislation was passed, and I’m not sure the pressures for that imperative are going to change qualitatively.”

One change Dr. Lee does foresee due to the legislation’s dependence on market reforms is that resulting insurance products will “spend a lot less money on patients than existing ones do. There are going to be a variety of pressures on doctors and hospitals to either be much more efficient or take less money for what they do,” he says. “Given that choice, most of us would rather become more efficient.”

Another consequence of affordable insurance products may be a narrowing of provider networks. And a narrow network product, says Sylvia C.W. McKean, MD, FACP, medical director of the BWH/Faulkner Hospitalist Service at Brigham and Women’s Hospital in Boston, “might result in a reduced number of patients going to tertiary care hospitals, which currently care for a large number of indigent patients.”

Even though standards of affordability and details of insurance products have yet to be generated by The Connector and insurers, Dr. Lee also believes that narrowing of benefits and networks will be one likely consequence of the legislation. This will entail some difficult choices about the range of services hospitals and physicians can offer. But, he says, “I think it’s worth doing painful, difficult stuff, and making painful, ugly choices in order for everyone to have necessary catastrophic care and to have access to basic preventive care. We should be willing to live with some of that ugly stuff because it will, in Massachusetts, at least, give us a chance of preventing the need for even uglier outcomes, which is, 10% of our population not having any coverage at all.”

Dr. Lee believes that hospitalists will be critical to the success of hospital efficiency. “To the extent that institutions can use hospitalists and other systems to become much more efficient and reduce readmissions, it’s going to mitigate the need for the narrowing of benefits and networks,” he says.

Now that these [formerly uninsured or underinsured] people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources.

—Glenn Allison, MD

Upshot for Hospitalists

Unknowns about the workability of and funding for the legislation abound. It’s not clear whether shifting costs to individuals (by mandating they purchase private insurance) and employers (via the $295 per employee fee) can bridge current deficits in compensation and care. Dr. Lee points out that “it’s still an open question of whether there is going to be enough money. But clearly, there are going to be insurance products that spend a lot less money on patients than existing ones do.”

Dr. Li does not believe these funding questions will affect the bottom line for his hospitalist group because their compensation is based on productivity, as measured by relative value units (RVUs).

The next 10 months or so leading up to the July 1, 2007, deadline for purchase of individual health insurance policies will be revealing for consumers and physicians alike. Although the devil will be in the details, Dr. Lee notes, “The big picture is not uncertain. We know there is going to be more transparency, more data, on quality and efficiency.”

That means that hospitals’ delivery of care will endure more scrutiny, and that pay for performance will become commonplace.

The influx of patients into the healthcare system, which legislators hope will be a consequence of greater access to care, will necessitate some consciousness-raising for hospitalists, Dr. Allison maintains. While hospitalists already work closely with other providers on the multidisciplinary team (social workers, case managers, and primary care physicians), they will have to strengthen those collaborations to ensure that patients don’t fall through the cracks. Community outreach may become part of the hospitalists’ job description.

For example, he explains, many preventive or follow-up services that are now being performed in the hospital because patients have no primary care physicians can now be referred to outpatient sites. “Now that these people will have doctors and will be tied into the healthcare system, these services can be performed in the right setting, instead of using more expensive inpatient resources,” he says.

Steering patients to community-based preventive services, such as early cardiac and cancer screenings, will fall to hospitalists, who will be “on the frontlines seeing these patients and referring them appropriately as they leave the hospital,” says Dr. Allison. Hospitalists and all providers will also be evaluated by how well they deliver culturally competent care—another mandate of the statute. To steer through these changes, hospitalists must become much more conscious, he says, of costs, communications, referrals, and resources. “That, as far as I can see, has not been a major emphasis of hospitalist literature or debate.”

A Role to Play

Dr. McKean and others contend that by virtue of their skill set and core mission, hospitalists will have much to contribute toward moderating the costs of healthcare. “The good news for hospitalists,” says Turnbull, “is that if we’re successful in providing health coverage to many people who are now uninsured and if that coverage is adequate there should be more people receiving primary and preventive care and services. This should prevent them from needing to go to the hospital in the first place. We should also be able to create more rational systems of care for people, so that when patients are in the hospital, they need to be there, and they can take full advantage of the talents and contributions that hospitalists make.”

Dr. Kingsdale agrees with the assessment that hospitalists will have a potentially significant role to play in improving the delivery, efficiency, and quality of care, as well as reducing medical errors. He hopes the new insurance products generated by companies will include financial incentives for hospitals and other providers who will be doing “the difficult work of changing their systems of care.”

“The healthcare system really has to improve,” asserts Dr. Lee. “In our organization, we say that we need both an industrial revolution and a cultural revolution, where we develop and use systems that reduce errors. There are electronic records and other industrial systems, and then there are human-ware systems, like hospitalists and disease management programs.”

Like the community organizations that must increase outreach efforts to formerly disenfranchised healthcare consumers, the administrators who fulfill the law’s mandates, and citizens who will be comparing new health plans, hospitalists may find themselves working harder once the law is implemented. The April legislation “elevates the stakes for delivering effective, quality inpatient care,” says Dr. Allison. “I don’t want to over-inflate our importance, but I do think in a system where so many of our healthcare dollars are expended on the inpatient side, we’ve got to be extremely conscious of what we do.” This may mean shifting hospitalists’ implicit skills into the explicit realm, he says: “For instance, everyone talks about guidelines and how helpful they are, but we don’t do a good enough job when it comes to using them. We need to do better with vaccination, with discharge instructions, and with communicating and coordinating care.

“I think the care coordination piece is going to be the key to success,” concludes Dr. Allison. “I think we need to take what we do now, but do more of it, and do a better job of it. That is something that will make a tough job even tougher. But I think if we fail in this, the whole effort may collapse.” TH

Gretchen Henkel is coauthor of Marketing Your Clinical Practice—Ethically, Effectively, Economically.

Resources

1. Altman SH, Doonan M. “Can Massachusetts lead the way in health care reform?” N Engl J Med. 2006 May;354(20):2093-2095.
2. Steinbrook R. Health care reform in Massachusetts—a work in progress. N Engl J Med. 2006 May;354(20): 2095-2098.
3. The 184th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006, an act providing access to affordable, quality, accountable health care. Available at: www.mass.gov/legis/summary.pdf). Last accessed June 12, 2006.
4. Johnston PW, Turnbull NC. A bold insurance experiment. The Boston Globe. April 16, 2006. Available at: www.boston.com. Last accessed June 26, 2006.
5. McCormick D, Himmelstein DU, Woolhandler S, et al. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004 Feb 9;164(3):300-304.
6. “Massachusetts Health Reform Bill: A False Promise of Universal Coverage.” Statement by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD. Available at www.pnhp.org/news/2006/april/massachusetts_health.php. Last accessed June 26, 2006.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD