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The impact of Election 2016
Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.
Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.
Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.
Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.
Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.
Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.
VIDEO: How to discharge new pediatric diabetes cases in 2 days
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT PHM 2017
Student Hospitalist Scholars: Discovering a passion for research
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.
I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.
I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.
Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?
After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.
Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.
I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.
Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.
I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.
I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.
Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?
After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.
Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.
I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.
Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.
I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.
I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.
Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?
After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.
Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.
I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.
Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.
C diff infection among U.S. ED patients
Title: C. diff infection common in emergency department patients, even without risk factors.
Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?
Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.
Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.
Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.
Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.
Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: C. diff infection common in emergency department patients, even without risk factors.
Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?
Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.
Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.
Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.
Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.
Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: C. diff infection common in emergency department patients, even without risk factors.
Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?
Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.
Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.
Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.
Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.
Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
Student Hospitalist Scholars: The importance of communication
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?
Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.
At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.
With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.
We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.
I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.
Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.
Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?
Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.
At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.
With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.
We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.
I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.
Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.
Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?
Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.
At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.
With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.
We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.
I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.
Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.
Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.
PEARL score for COPD exacerbations
TITLE: PEARL score predicts COPD readmissions
CLINICAL QUESTION: Which prognostic score is best at predicting 90-day readmission and mortality for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?
STUDY DESIGN: Prospective study with three separate cohorts: derivation, internal validation, and external validation.
SETTING: Six hospitals in the United Kingdom.
SYNOPSIS: 2,417 patients were included and 936 were readmitted or died within 90 days of index admission. Patients with expected survival for less than 1 year for reasons other than COPD were excluded. The indices retained in the final PEARL score were: Previous admissions for AECOPD of 2 or more (2 points), extended medical research council (MRC) dyspnea score of 4, 5a or 5b (1, 2, or 3 points), age of 80 or older (1 point), clinical diagnoses of right-sided heart failure (1 point) and/or left-sided heart failure on echocardiogram (1 point). Higher scores were associated with a shorter time to death or readmission. The performance of PEARL was superior to all alternative scoring systems. The major limitation to this study is that it did not differentiate between respiratory and other causes of readmission.
BOTTOM LINE: The PEARL score can be calculated for patients hospitalized for AECOPD to predict their 90-day readmission rate and/or mortality risk.
CITATION: Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, et al. The PEARL score predicts 90-day readmission or death after hospitalization for acute exacerbation of COPD. Thorax. 2017; doi: 10.1136/thoraxjnl-2016-209298.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
TITLE: PEARL score predicts COPD readmissions
CLINICAL QUESTION: Which prognostic score is best at predicting 90-day readmission and mortality for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?
STUDY DESIGN: Prospective study with three separate cohorts: derivation, internal validation, and external validation.
SETTING: Six hospitals in the United Kingdom.
SYNOPSIS: 2,417 patients were included and 936 were readmitted or died within 90 days of index admission. Patients with expected survival for less than 1 year for reasons other than COPD were excluded. The indices retained in the final PEARL score were: Previous admissions for AECOPD of 2 or more (2 points), extended medical research council (MRC) dyspnea score of 4, 5a or 5b (1, 2, or 3 points), age of 80 or older (1 point), clinical diagnoses of right-sided heart failure (1 point) and/or left-sided heart failure on echocardiogram (1 point). Higher scores were associated with a shorter time to death or readmission. The performance of PEARL was superior to all alternative scoring systems. The major limitation to this study is that it did not differentiate between respiratory and other causes of readmission.
BOTTOM LINE: The PEARL score can be calculated for patients hospitalized for AECOPD to predict their 90-day readmission rate and/or mortality risk.
CITATION: Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, et al. The PEARL score predicts 90-day readmission or death after hospitalization for acute exacerbation of COPD. Thorax. 2017; doi: 10.1136/thoraxjnl-2016-209298.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
TITLE: PEARL score predicts COPD readmissions
CLINICAL QUESTION: Which prognostic score is best at predicting 90-day readmission and mortality for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?
STUDY DESIGN: Prospective study with three separate cohorts: derivation, internal validation, and external validation.
SETTING: Six hospitals in the United Kingdom.
SYNOPSIS: 2,417 patients were included and 936 were readmitted or died within 90 days of index admission. Patients with expected survival for less than 1 year for reasons other than COPD were excluded. The indices retained in the final PEARL score were: Previous admissions for AECOPD of 2 or more (2 points), extended medical research council (MRC) dyspnea score of 4, 5a or 5b (1, 2, or 3 points), age of 80 or older (1 point), clinical diagnoses of right-sided heart failure (1 point) and/or left-sided heart failure on echocardiogram (1 point). Higher scores were associated with a shorter time to death or readmission. The performance of PEARL was superior to all alternative scoring systems. The major limitation to this study is that it did not differentiate between respiratory and other causes of readmission.
BOTTOM LINE: The PEARL score can be calculated for patients hospitalized for AECOPD to predict their 90-day readmission rate and/or mortality risk.
CITATION: Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, et al. The PEARL score predicts 90-day readmission or death after hospitalization for acute exacerbation of COPD. Thorax. 2017; doi: 10.1136/thoraxjnl-2016-209298.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
Student Hospitalist Scholars: Preventing unplanned PICU transfers
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.
I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.
We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.
So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.
I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.
I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.
After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.
I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.
Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.
I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.
We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.
So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.
I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.
I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.
After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.
I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.
Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.
I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.
We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.
So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.
I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.
I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.
After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.
I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.
Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.
Large-scale implementation of the I-PASS handover system
Title: Large-scale implementation of the I-PASS handover system at an academic medical center
Clinical Question: Is a system-wide I-PASS handover system able to be effectively implemented?
Background: Handovers (also referred to as “handoffs”) in patient care are ubiquitous and are increasing, especially in academic medicine. Errors in handovers are associated with poor patient outcomes. I-PASS (Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver) is a handover system that is thought to improve efficiency and accuracy of handovers, however generalized roll-out within a large academic hospital remains daunting.
Setting: Academic medical center.
Synopsis: The authors recount a 3-year system-wide I-PASS implementation at their 999-bed major academic medical center. Effectiveness was measured through surveys and direct observations. Postimplementation surveys demonstrated a generally positive response to the implementation and training processes. Direct observation over 8 months was used to assess adoption and adherence to the handover method, and results showed improvement across all aspects of the I-PASS model, although the synthesis component of the handover consistently scored lowest. The authors noted that this is an ongoing project and plan future studies to evaluate effect on quality and safety measures.
Bottom Line: Implementing a system-wide handover change process is achievable, but will need to be incorporated into organizational culture to ensure continued use.
Citation: Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical center. BMJ Qual Saf. 2017; doi: 10.1136/bmjqs-2016006195.
Dr. Rankin is a hospitalist and director of the family medicine residency inpatient service at the University of New Mexico.
Title: Large-scale implementation of the I-PASS handover system at an academic medical center
Clinical Question: Is a system-wide I-PASS handover system able to be effectively implemented?
Background: Handovers (also referred to as “handoffs”) in patient care are ubiquitous and are increasing, especially in academic medicine. Errors in handovers are associated with poor patient outcomes. I-PASS (Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver) is a handover system that is thought to improve efficiency and accuracy of handovers, however generalized roll-out within a large academic hospital remains daunting.
Setting: Academic medical center.
Synopsis: The authors recount a 3-year system-wide I-PASS implementation at their 999-bed major academic medical center. Effectiveness was measured through surveys and direct observations. Postimplementation surveys demonstrated a generally positive response to the implementation and training processes. Direct observation over 8 months was used to assess adoption and adherence to the handover method, and results showed improvement across all aspects of the I-PASS model, although the synthesis component of the handover consistently scored lowest. The authors noted that this is an ongoing project and plan future studies to evaluate effect on quality and safety measures.
Bottom Line: Implementing a system-wide handover change process is achievable, but will need to be incorporated into organizational culture to ensure continued use.
Citation: Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical center. BMJ Qual Saf. 2017; doi: 10.1136/bmjqs-2016006195.
Dr. Rankin is a hospitalist and director of the family medicine residency inpatient service at the University of New Mexico.
Title: Large-scale implementation of the I-PASS handover system at an academic medical center
Clinical Question: Is a system-wide I-PASS handover system able to be effectively implemented?
Background: Handovers (also referred to as “handoffs”) in patient care are ubiquitous and are increasing, especially in academic medicine. Errors in handovers are associated with poor patient outcomes. I-PASS (Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver) is a handover system that is thought to improve efficiency and accuracy of handovers, however generalized roll-out within a large academic hospital remains daunting.
Setting: Academic medical center.
Synopsis: The authors recount a 3-year system-wide I-PASS implementation at their 999-bed major academic medical center. Effectiveness was measured through surveys and direct observations. Postimplementation surveys demonstrated a generally positive response to the implementation and training processes. Direct observation over 8 months was used to assess adoption and adherence to the handover method, and results showed improvement across all aspects of the I-PASS model, although the synthesis component of the handover consistently scored lowest. The authors noted that this is an ongoing project and plan future studies to evaluate effect on quality and safety measures.
Bottom Line: Implementing a system-wide handover change process is achievable, but will need to be incorporated into organizational culture to ensure continued use.
Citation: Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical center. BMJ Qual Saf. 2017; doi: 10.1136/bmjqs-2016006195.
Dr. Rankin is a hospitalist and director of the family medicine residency inpatient service at the University of New Mexico.
CCDSSs to prevent VTE
Title: Use of computerized clinical decision support systems decreases venous thromboembolic events in surgical patients
Clinical Question: Do computerized clinical decision support systems (CCDSSs) decrease the risk of venous thromboembolism (VTE) in surgical patients?
Background: VTE remains the leading preventable cause of death in the hospital. Despite multiple tools that are available to stratify risk of VTE, they are not used uniformly or are used incorrectly. It is unclear whether CCDSSs help prevent VTE compared to standard care.
Study Design: Retrospective systematic review and meta-analysis.
Setting: 188 studies initially screened, 11 studies were included.
Synopsis: Multiple studies relevant to the topic were reviewed; only studies that used an electronic medical record (EMR)–based tool to augment the rate of appropriate prophylaxis of VTE were included. Primary outcomes assessed were rate of appropriate prophylaxis for VTE and rate of VTE events. A total of 156,366 patients were analyzed, of which 104,241 (66%) received intervention with CCDSSs and 52,125 (33%) received standard care (physician judgment and discretion). The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% confidence interval, 1.78-3.10; P less than .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P less than .001). The major limitation of this study is that it did not evaluate the number of adverse events as a result of VTE prophylaxis, such as bleeding, which may have been significantly increased in the CCDSS group.
Bottom Line: The use of CCDSSs increases the proportion of surgical patients who are prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.
Citation: Borab ZM, Lanni MA, Tecce MG, Pannucci CJ, Fischer JP. Use of computerized clinical decision support systems to prevent venous thromboembolism in surgical patients: A systematic review and meta-analysis. JAMA Surg. 2017; doi: 10.1001/jamasurg.2017.0131.
Dr. Mayasy is assistant professor in the department of hospital medicine at the University of New Mexico.
Title: Use of computerized clinical decision support systems decreases venous thromboembolic events in surgical patients
Clinical Question: Do computerized clinical decision support systems (CCDSSs) decrease the risk of venous thromboembolism (VTE) in surgical patients?
Background: VTE remains the leading preventable cause of death in the hospital. Despite multiple tools that are available to stratify risk of VTE, they are not used uniformly or are used incorrectly. It is unclear whether CCDSSs help prevent VTE compared to standard care.
Study Design: Retrospective systematic review and meta-analysis.
Setting: 188 studies initially screened, 11 studies were included.
Synopsis: Multiple studies relevant to the topic were reviewed; only studies that used an electronic medical record (EMR)–based tool to augment the rate of appropriate prophylaxis of VTE were included. Primary outcomes assessed were rate of appropriate prophylaxis for VTE and rate of VTE events. A total of 156,366 patients were analyzed, of which 104,241 (66%) received intervention with CCDSSs and 52,125 (33%) received standard care (physician judgment and discretion). The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% confidence interval, 1.78-3.10; P less than .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P less than .001). The major limitation of this study is that it did not evaluate the number of adverse events as a result of VTE prophylaxis, such as bleeding, which may have been significantly increased in the CCDSS group.
Bottom Line: The use of CCDSSs increases the proportion of surgical patients who are prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.
Citation: Borab ZM, Lanni MA, Tecce MG, Pannucci CJ, Fischer JP. Use of computerized clinical decision support systems to prevent venous thromboembolism in surgical patients: A systematic review and meta-analysis. JAMA Surg. 2017; doi: 10.1001/jamasurg.2017.0131.
Dr. Mayasy is assistant professor in the department of hospital medicine at the University of New Mexico.
Title: Use of computerized clinical decision support systems decreases venous thromboembolic events in surgical patients
Clinical Question: Do computerized clinical decision support systems (CCDSSs) decrease the risk of venous thromboembolism (VTE) in surgical patients?
Background: VTE remains the leading preventable cause of death in the hospital. Despite multiple tools that are available to stratify risk of VTE, they are not used uniformly or are used incorrectly. It is unclear whether CCDSSs help prevent VTE compared to standard care.
Study Design: Retrospective systematic review and meta-analysis.
Setting: 188 studies initially screened, 11 studies were included.
Synopsis: Multiple studies relevant to the topic were reviewed; only studies that used an electronic medical record (EMR)–based tool to augment the rate of appropriate prophylaxis of VTE were included. Primary outcomes assessed were rate of appropriate prophylaxis for VTE and rate of VTE events. A total of 156,366 patients were analyzed, of which 104,241 (66%) received intervention with CCDSSs and 52,125 (33%) received standard care (physician judgment and discretion). The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% confidence interval, 1.78-3.10; P less than .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P less than .001). The major limitation of this study is that it did not evaluate the number of adverse events as a result of VTE prophylaxis, such as bleeding, which may have been significantly increased in the CCDSS group.
Bottom Line: The use of CCDSSs increases the proportion of surgical patients who are prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.
Citation: Borab ZM, Lanni MA, Tecce MG, Pannucci CJ, Fischer JP. Use of computerized clinical decision support systems to prevent venous thromboembolism in surgical patients: A systematic review and meta-analysis. JAMA Surg. 2017; doi: 10.1001/jamasurg.2017.0131.
Dr. Mayasy is assistant professor in the department of hospital medicine at the University of New Mexico.
Variation in physician spending and association with patient outcomes
Title: Variation in physician spending not associated with patient outcomes
Clinical Question: Is there a variation in spending between physicians in the same hospital, and does it have an effect on patient outcomes?
Background: Not much is known about the presence of variations in individual physician spending within the same hospital and it is not known if higher-spending physicians have better patient outcomes compared to peers within the same institution.
Setting: National sample of hospitalized Medicare beneficiaries.
Synopsis: Using National Medicare data over a 4-year period, the authors showed that there is wide variation in Part B spending across physicians (hospitalists and general internists) within the same acute care hospital. This inter-physician variation is larger than the difference in spending across hospitals. Higher spending was not associated with a reduction in 30-day mortality or 30-day readmission rates.
Most current health reform policies such as value-based purchasing and 30-day readmission penalties target hospitals as entities, but based on this study there may be a role for more physician-specific reform options. Because they found no significant difference in quality outcomes based on spending, the authors postulate that there may be an opportunity for individual high-spending physicians to decrease their health care utilization without compromising care quality.
The major limitation to this study is that it is a large-scale data analysis and may not capture some of the intricacies of individualized patient care.
Bottom Line: Spending varies across physicians within the same hospital, and is not associated with differences in mortality or readmissions outcomes.
Citation: Tsugawa Y, Jha AK, Newhouse JP, Zaslavsky AM, Jena AB. Variation in Physician Spending and Association With Patient Outcomes. JAMA Intern Med. 2017. doi: 10.1001/jamainternmed.2017.0059.
Dr. Rankin is a hospitalist and director of the family medicine residency inpatient service at the University of New Mexico.
Title: Variation in physician spending not associated with patient outcomes
Clinical Question: Is there a variation in spending between physicians in the same hospital, and does it have an effect on patient outcomes?
Background: Not much is known about the presence of variations in individual physician spending within the same hospital and it is not known if higher-spending physicians have better patient outcomes compared to peers within the same institution.
Setting: National sample of hospitalized Medicare beneficiaries.
Synopsis: Using National Medicare data over a 4-year period, the authors showed that there is wide variation in Part B spending across physicians (hospitalists and general internists) within the same acute care hospital. This inter-physician variation is larger than the difference in spending across hospitals. Higher spending was not associated with a reduction in 30-day mortality or 30-day readmission rates.
Most current health reform policies such as value-based purchasing and 30-day readmission penalties target hospitals as entities, but based on this study there may be a role for more physician-specific reform options. Because they found no significant difference in quality outcomes based on spending, the authors postulate that there may be an opportunity for individual high-spending physicians to decrease their health care utilization without compromising care quality.
The major limitation to this study is that it is a large-scale data analysis and may not capture some of the intricacies of individualized patient care.
Bottom Line: Spending varies across physicians within the same hospital, and is not associated with differences in mortality or readmissions outcomes.
Citation: Tsugawa Y, Jha AK, Newhouse JP, Zaslavsky AM, Jena AB. Variation in Physician Spending and Association With Patient Outcomes. JAMA Intern Med. 2017. doi: 10.1001/jamainternmed.2017.0059.
Dr. Rankin is a hospitalist and director of the family medicine residency inpatient service at the University of New Mexico.
Title: Variation in physician spending not associated with patient outcomes
Clinical Question: Is there a variation in spending between physicians in the same hospital, and does it have an effect on patient outcomes?
Background: Not much is known about the presence of variations in individual physician spending within the same hospital and it is not known if higher-spending physicians have better patient outcomes compared to peers within the same institution.
Setting: National sample of hospitalized Medicare beneficiaries.
Synopsis: Using National Medicare data over a 4-year period, the authors showed that there is wide variation in Part B spending across physicians (hospitalists and general internists) within the same acute care hospital. This inter-physician variation is larger than the difference in spending across hospitals. Higher spending was not associated with a reduction in 30-day mortality or 30-day readmission rates.
Most current health reform policies such as value-based purchasing and 30-day readmission penalties target hospitals as entities, but based on this study there may be a role for more physician-specific reform options. Because they found no significant difference in quality outcomes based on spending, the authors postulate that there may be an opportunity for individual high-spending physicians to decrease their health care utilization without compromising care quality.
The major limitation to this study is that it is a large-scale data analysis and may not capture some of the intricacies of individualized patient care.
Bottom Line: Spending varies across physicians within the same hospital, and is not associated with differences in mortality or readmissions outcomes.
Citation: Tsugawa Y, Jha AK, Newhouse JP, Zaslavsky AM, Jena AB. Variation in Physician Spending and Association With Patient Outcomes. JAMA Intern Med. 2017. doi: 10.1001/jamainternmed.2017.0059.
Dr. Rankin is a hospitalist and director of the family medicine residency inpatient service at the University of New Mexico.