All Content

NEW ORLEANS – Antibiotic shortages reported by the Emerging Infections Network (EIN) in 2011 persist in 2016, according to a web-based follow-up survey of infectious disease physicians.

Of 701 network members who responded to the EIN survey in early 2016, 70% reported needing to modify their antimicrobial choice because of a shortage in the past 2 years. They did so by using broader-spectrum agents (75% of respondents), more costly agents (58%), less effective second-line agents (45%), and more toxic agents (37%), Adi Gundlapalli, MD, PhD, reported at an annual scientific meeting on infectious diseases.

In addition, 73% of respondents reported that the shortages affected patient care or outcomes, reported Dr. Gundlapalli of the University of Utah, Salt Lake City.

The percentage of respondents reporting adverse patient outcomes related to shortages increased from 2011 to 2016 (51% vs.73%), he noted at the combined annual meetings of the Infectious Diseases Society of America, the Society of Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

The top 10 antimicrobials they reported as being in short supply were piperacillin-tazobactam, ampicillin-sulbactam, meropenem, cefotaxime, cefepime, trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, imipenem, acyclovir, and amikacin. TMP-SMX and acyclovir were in short supply at both time points.

The most common ways respondents reported learning about drug shortages were from hospital notification (76%), from a colleague (56%), from a pharmacy that contacted them regarding a prescription for the agent (53%), or from the Food and Drug Administration website or another website on shortages (23%). The most common ways of learning about a shortage changed – from notification after trying to prescribe a drug in 2011, to proactive hospital/system (local) notification in 2016; 71% of respondents said that communications in 2016 were sufficient.

Most respondents (83%) reported that guidelines for dealing with shortages had been developed by an antimicrobial stewardship program (ASP) at their institution.

“This, I think, is one of the highlight results,” said Dr. Gundlapalli, who is also a staff physician at the VA Salt Lake City Health System. “In 2011, we had no specific question or comments received about [ASPs], and here in 2016, 83% of respondents’ institutions had developed guidelines related to drug shortages.”

Respondents also had the opportunity to submit free-text responses, and among the themes that emerged was concern regarding toxicity and adverse outcomes associated with increased use of aminoglycosides because of the shortage of piperacillin-tazobactam. Another – described as a blessing in disguise – was the shortage of meropenem, which led one ASP to “institute restrictions on its use, which have continued,” he said.

“Another theme was ‘simpler agents seem more likely to be in shortage,’ ” Dr. Gundlapalli said, noting ampicillin-sulbactam in 2016 and Pen-G as examples.

“And then, of course, the other theme across the board ... was our new asset,” he said, explaining that some respondents commented on the value of ASP pharmacists and programs to help with drug shortage issues.

The overall theme of this follow-up survey, in the context of prior surveys in 2001 and 2011, is that antibiotic shortages are the “new normal – a way of life,” Dr. Gundlapalli said.

“The concerns do persist, and we feel there is further work to be done here,” he said. He specifically noted that there is a need to inform and educate fellows and colleagues in hospitals, increase awareness generally, improve communication strategies, and conduct detailed studies on adverse effects and outcomes.

“And now, since ASPs are very pervasive ... maybe it’s time to formalize and delineate the role of ASPs in antimicrobial shortages,” he said.

The problem of antibiotic shortages “harkens back to the day when penicillin was recycled in the urine [of soldiers in World War II] to save this very scarce resource ... but that’s a very extreme measure to take,” noted Donald Graham, MD, of the Springfield (Ill.) Clinic, one of the study’s coauthors. “It seems like it’s time for the other federal arm – namely, the Food and Drug Administration – to do something about this.”

Dr. Graham said he believes the problem is in part because of economics, and in part because of “the higher standards that the FDA imposes upon these manufacturing concerns.” These drugs often are low-profit items, and it isn’t always in the financial best interest of a pharmaceutical company to upgrade their facilities.

“But they really have to recognize the importance of having availability of these simple agents,” he said, pleading with any FDA representatives in the audience to “maybe think about some of these very high standards.”

Dr. Gundlapalli reported having no disclosures. Dr. Graham disclosed relationships with Astellas and Theravance Biopharma.

[email protected]

NEW ORLEANS – Antibiotic shortages reported by the Emerging Infections Network (EIN) in 2011 persist in 2016, according to a web-based follow-up survey of infectious disease physicians.

Of 701 network members who responded to the EIN survey in early 2016, 70% reported needing to modify their antimicrobial choice because of a shortage in the past 2 years. They did so by using broader-spectrum agents (75% of respondents), more costly agents (58%), less effective second-line agents (45%), and more toxic agents (37%), Adi Gundlapalli, MD, PhD, reported at an annual scientific meeting on infectious diseases.

In addition, 73% of respondents reported that the shortages affected patient care or outcomes, reported Dr. Gundlapalli of the University of Utah, Salt Lake City.

The percentage of respondents reporting adverse patient outcomes related to shortages increased from 2011 to 2016 (51% vs.73%), he noted at the combined annual meetings of the Infectious Diseases Society of America, the Society of Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

The top 10 antimicrobials they reported as being in short supply were piperacillin-tazobactam, ampicillin-sulbactam, meropenem, cefotaxime, cefepime, trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, imipenem, acyclovir, and amikacin. TMP-SMX and acyclovir were in short supply at both time points.

The most common ways respondents reported learning about drug shortages were from hospital notification (76%), from a colleague (56%), from a pharmacy that contacted them regarding a prescription for the agent (53%), or from the Food and Drug Administration website or another website on shortages (23%). The most common ways of learning about a shortage changed – from notification after trying to prescribe a drug in 2011, to proactive hospital/system (local) notification in 2016; 71% of respondents said that communications in 2016 were sufficient.

Most respondents (83%) reported that guidelines for dealing with shortages had been developed by an antimicrobial stewardship program (ASP) at their institution.

“This, I think, is one of the highlight results,” said Dr. Gundlapalli, who is also a staff physician at the VA Salt Lake City Health System. “In 2011, we had no specific question or comments received about [ASPs], and here in 2016, 83% of respondents’ institutions had developed guidelines related to drug shortages.”

Respondents also had the opportunity to submit free-text responses, and among the themes that emerged was concern regarding toxicity and adverse outcomes associated with increased use of aminoglycosides because of the shortage of piperacillin-tazobactam. Another – described as a blessing in disguise – was the shortage of meropenem, which led one ASP to “institute restrictions on its use, which have continued,” he said.

“Another theme was ‘simpler agents seem more likely to be in shortage,’ ” Dr. Gundlapalli said, noting ampicillin-sulbactam in 2016 and Pen-G as examples.

“And then, of course, the other theme across the board ... was our new asset,” he said, explaining that some respondents commented on the value of ASP pharmacists and programs to help with drug shortage issues.

The overall theme of this follow-up survey, in the context of prior surveys in 2001 and 2011, is that antibiotic shortages are the “new normal – a way of life,” Dr. Gundlapalli said.

“The concerns do persist, and we feel there is further work to be done here,” he said. He specifically noted that there is a need to inform and educate fellows and colleagues in hospitals, increase awareness generally, improve communication strategies, and conduct detailed studies on adverse effects and outcomes.

“And now, since ASPs are very pervasive ... maybe it’s time to formalize and delineate the role of ASPs in antimicrobial shortages,” he said.

The problem of antibiotic shortages “harkens back to the day when penicillin was recycled in the urine [of soldiers in World War II] to save this very scarce resource ... but that’s a very extreme measure to take,” noted Donald Graham, MD, of the Springfield (Ill.) Clinic, one of the study’s coauthors. “It seems like it’s time for the other federal arm – namely, the Food and Drug Administration – to do something about this.”

Dr. Graham said he believes the problem is in part because of economics, and in part because of “the higher standards that the FDA imposes upon these manufacturing concerns.” These drugs often are low-profit items, and it isn’t always in the financial best interest of a pharmaceutical company to upgrade their facilities.

“But they really have to recognize the importance of having availability of these simple agents,” he said, pleading with any FDA representatives in the audience to “maybe think about some of these very high standards.”

Dr. Gundlapalli reported having no disclosures. Dr. Graham disclosed relationships with Astellas and Theravance Biopharma.

[email protected]

NEW ORLEANS – Antibiotic shortages reported by the Emerging Infections Network (EIN) in 2011 persist in 2016, according to a web-based follow-up survey of infectious disease physicians.

Of 701 network members who responded to the EIN survey in early 2016, 70% reported needing to modify their antimicrobial choice because of a shortage in the past 2 years. They did so by using broader-spectrum agents (75% of respondents), more costly agents (58%), less effective second-line agents (45%), and more toxic agents (37%), Adi Gundlapalli, MD, PhD, reported at an annual scientific meeting on infectious diseases.

In addition, 73% of respondents reported that the shortages affected patient care or outcomes, reported Dr. Gundlapalli of the University of Utah, Salt Lake City.

The percentage of respondents reporting adverse patient outcomes related to shortages increased from 2011 to 2016 (51% vs.73%), he noted at the combined annual meetings of the Infectious Diseases Society of America, the Society of Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

The top 10 antimicrobials they reported as being in short supply were piperacillin-tazobactam, ampicillin-sulbactam, meropenem, cefotaxime, cefepime, trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, imipenem, acyclovir, and amikacin. TMP-SMX and acyclovir were in short supply at both time points.

The most common ways respondents reported learning about drug shortages were from hospital notification (76%), from a colleague (56%), from a pharmacy that contacted them regarding a prescription for the agent (53%), or from the Food and Drug Administration website or another website on shortages (23%). The most common ways of learning about a shortage changed – from notification after trying to prescribe a drug in 2011, to proactive hospital/system (local) notification in 2016; 71% of respondents said that communications in 2016 were sufficient.

Most respondents (83%) reported that guidelines for dealing with shortages had been developed by an antimicrobial stewardship program (ASP) at their institution.

“This, I think, is one of the highlight results,” said Dr. Gundlapalli, who is also a staff physician at the VA Salt Lake City Health System. “In 2011, we had no specific question or comments received about [ASPs], and here in 2016, 83% of respondents’ institutions had developed guidelines related to drug shortages.”

Respondents also had the opportunity to submit free-text responses, and among the themes that emerged was concern regarding toxicity and adverse outcomes associated with increased use of aminoglycosides because of the shortage of piperacillin-tazobactam. Another – described as a blessing in disguise – was the shortage of meropenem, which led one ASP to “institute restrictions on its use, which have continued,” he said.

“Another theme was ‘simpler agents seem more likely to be in shortage,’ ” Dr. Gundlapalli said, noting ampicillin-sulbactam in 2016 and Pen-G as examples.

“And then, of course, the other theme across the board ... was our new asset,” he said, explaining that some respondents commented on the value of ASP pharmacists and programs to help with drug shortage issues.

The overall theme of this follow-up survey, in the context of prior surveys in 2001 and 2011, is that antibiotic shortages are the “new normal – a way of life,” Dr. Gundlapalli said.

“The concerns do persist, and we feel there is further work to be done here,” he said. He specifically noted that there is a need to inform and educate fellows and colleagues in hospitals, increase awareness generally, improve communication strategies, and conduct detailed studies on adverse effects and outcomes.

“And now, since ASPs are very pervasive ... maybe it’s time to formalize and delineate the role of ASPs in antimicrobial shortages,” he said.

The problem of antibiotic shortages “harkens back to the day when penicillin was recycled in the urine [of soldiers in World War II] to save this very scarce resource ... but that’s a very extreme measure to take,” noted Donald Graham, MD, of the Springfield (Ill.) Clinic, one of the study’s coauthors. “It seems like it’s time for the other federal arm – namely, the Food and Drug Administration – to do something about this.”

Dr. Graham said he believes the problem is in part because of economics, and in part because of “the higher standards that the FDA imposes upon these manufacturing concerns.” These drugs often are low-profit items, and it isn’t always in the financial best interest of a pharmaceutical company to upgrade their facilities.

“But they really have to recognize the importance of having availability of these simple agents,” he said, pleading with any FDA representatives in the audience to “maybe think about some of these very high standards.”

Dr. Gundlapalli reported having no disclosures. Dr. Graham disclosed relationships with Astellas and Theravance Biopharma.

[email protected]

SHM recently partnered with the Human Diagnosis Project, also referred to as Human Dx, for Global Morning Report. Human Dx is the world’s first open diagnostic system, which aims to understand the fundamental data structure of diagnosis and considerably impact the future cost of, access to, and effectiveness of healthcare globally.

The Hospitalist spoke with Shantanu Nundy, MD, MBA, a primary-care physician for the Human Diagnosis Project, to learn more about its inception and SHM’s partnership.

Question: How did the Global Morning Report project start?

Answer: We were at the University of California, San Francisco (UCSF), working on a morning report with master diagnostician Gurpreet Dhaliwal, MD, when we had an “aha moment” of sorts. Instead of the typical morning report, which uses a whiteboard or slide deck, residents and Dr. Dhaliwal worked through the case using the Human Dx open case collaboration software. At the end of the morning report, the case was tweeted out on social media for anyone in the world to solve, and within minutes, a medical student in Bangladesh not only was able to access the case but also access insights from the UCSF residents and Dr. Dhaliwal. That’s when we realized we were onto something big.

Q: What are the goals of Human Dx and Global Morning Report?

A: Repeated, rapid cycles of practice, feedback, and reinforcement are key components of learning. Sports training is a useful analogy—the best athletes practice drills daily, often for hours a day, and monitor their performance rigorously—but the same can be said for many other professions, including musicians, chefs, and public speakers.

In medicine, we call seeing patients every day “practice.” But we aren’t practicing if we aren’t getting feedback and improving—we are just performing. None of us can hope to be the Michael Phelps, Yo-Yo Ma, or Grant Achatz of medicine that our patients deserve us to be without real practice.

Human Dx builds on the science of learning by enabling physicians and students to quickly test and get feedback on their clinical reasoning skills. This is done both by receiving input on their own cases as well as giving input on other contributors’ cases to compare their thinking with physicians and students from around the world. Our goal is for Global Morning Report to become the daily personalized workout schedule for doctors everywhere. What I’d like to see is that rigorous practice and pursuit of excellence in clinical reasoning, diagnosis, and management becoming a core part of the physician experience.

Q: What kind of feedback are you hearing from participants?

A: Doctors love it! Many tell us this is their daily Sudoku or crossword that they do every morning to wake their minds up on the way to work. And our numbers show it: The average active participant contributes five cases per week. And today, that’s without any CME credit or other clear reward other than learning and enjoyment.

That said, we have much to improve, and we aren’t resting on our laurels. The whole ethos of the Human Diagnosis Project is created and led by the global medical community. We are lucky to have an incredible community of physicians and trainees globally who keep us moving forward each day.

Q: Why was a partnership with SHM appealing for this project?

A: At Human Dx, we look at ourselves simply as enablers. We are making it possible for the global medical community to come together and build something important for current and future generations. As such, we want to work with the best institutions in medicine to take their expertise, content, and community and make them more available to the world. As one of the largest, fastest growing, and innovative communities in medicine, SHM is an ideal partner, and we count ourselves very fortunate to have your support.

Q: How can hospitalists participate?

A: Start contributing cases! Not every doctor is interested in medical education, technology, or policy, but every physician I know has great cases and insights to share with the world. My hope is that for physicians and medical students, contributing to Human Dx is their 10 minutes a day to be a part of something greater than themselves, allowing them to share their insights with humankind, build a resource for current and future generations, and, in doing so, renew the reasons that brought them to medicine in the first place and find joy in clinical practice. TH

Join the movement today and solve a case now at www.humandx.org/shm.

SHM recently partnered with the Human Diagnosis Project, also referred to as Human Dx, for Global Morning Report. Human Dx is the world’s first open diagnostic system, which aims to understand the fundamental data structure of diagnosis and considerably impact the future cost of, access to, and effectiveness of healthcare globally.

The Hospitalist spoke with Shantanu Nundy, MD, MBA, a primary-care physician for the Human Diagnosis Project, to learn more about its inception and SHM’s partnership.

Question: How did the Global Morning Report project start?

Answer: We were at the University of California, San Francisco (UCSF), working on a morning report with master diagnostician Gurpreet Dhaliwal, MD, when we had an “aha moment” of sorts. Instead of the typical morning report, which uses a whiteboard or slide deck, residents and Dr. Dhaliwal worked through the case using the Human Dx open case collaboration software. At the end of the morning report, the case was tweeted out on social media for anyone in the world to solve, and within minutes, a medical student in Bangladesh not only was able to access the case but also access insights from the UCSF residents and Dr. Dhaliwal. That’s when we realized we were onto something big.

Q: What are the goals of Human Dx and Global Morning Report?

A: Repeated, rapid cycles of practice, feedback, and reinforcement are key components of learning. Sports training is a useful analogy—the best athletes practice drills daily, often for hours a day, and monitor their performance rigorously—but the same can be said for many other professions, including musicians, chefs, and public speakers.

In medicine, we call seeing patients every day “practice.” But we aren’t practicing if we aren’t getting feedback and improving—we are just performing. None of us can hope to be the Michael Phelps, Yo-Yo Ma, or Grant Achatz of medicine that our patients deserve us to be without real practice.

Human Dx builds on the science of learning by enabling physicians and students to quickly test and get feedback on their clinical reasoning skills. This is done both by receiving input on their own cases as well as giving input on other contributors’ cases to compare their thinking with physicians and students from around the world. Our goal is for Global Morning Report to become the daily personalized workout schedule for doctors everywhere. What I’d like to see is that rigorous practice and pursuit of excellence in clinical reasoning, diagnosis, and management becoming a core part of the physician experience.

Q: What kind of feedback are you hearing from participants?

A: Doctors love it! Many tell us this is their daily Sudoku or crossword that they do every morning to wake their minds up on the way to work. And our numbers show it: The average active participant contributes five cases per week. And today, that’s without any CME credit or other clear reward other than learning and enjoyment.

That said, we have much to improve, and we aren’t resting on our laurels. The whole ethos of the Human Diagnosis Project is created and led by the global medical community. We are lucky to have an incredible community of physicians and trainees globally who keep us moving forward each day.

Q: Why was a partnership with SHM appealing for this project?

A: At Human Dx, we look at ourselves simply as enablers. We are making it possible for the global medical community to come together and build something important for current and future generations. As such, we want to work with the best institutions in medicine to take their expertise, content, and community and make them more available to the world. As one of the largest, fastest growing, and innovative communities in medicine, SHM is an ideal partner, and we count ourselves very fortunate to have your support.

Q: How can hospitalists participate?

A: Start contributing cases! Not every doctor is interested in medical education, technology, or policy, but every physician I know has great cases and insights to share with the world. My hope is that for physicians and medical students, contributing to Human Dx is their 10 minutes a day to be a part of something greater than themselves, allowing them to share their insights with humankind, build a resource for current and future generations, and, in doing so, renew the reasons that brought them to medicine in the first place and find joy in clinical practice. TH

Join the movement today and solve a case now at www.humandx.org/shm.

SHM recently partnered with the Human Diagnosis Project, also referred to as Human Dx, for Global Morning Report. Human Dx is the world’s first open diagnostic system, which aims to understand the fundamental data structure of diagnosis and considerably impact the future cost of, access to, and effectiveness of healthcare globally.

The Hospitalist spoke with Shantanu Nundy, MD, MBA, a primary-care physician for the Human Diagnosis Project, to learn more about its inception and SHM’s partnership.

Question: How did the Global Morning Report project start?

Answer: We were at the University of California, San Francisco (UCSF), working on a morning report with master diagnostician Gurpreet Dhaliwal, MD, when we had an “aha moment” of sorts. Instead of the typical morning report, which uses a whiteboard or slide deck, residents and Dr. Dhaliwal worked through the case using the Human Dx open case collaboration software. At the end of the morning report, the case was tweeted out on social media for anyone in the world to solve, and within minutes, a medical student in Bangladesh not only was able to access the case but also access insights from the UCSF residents and Dr. Dhaliwal. That’s when we realized we were onto something big.

Q: What are the goals of Human Dx and Global Morning Report?

A: Repeated, rapid cycles of practice, feedback, and reinforcement are key components of learning. Sports training is a useful analogy—the best athletes practice drills daily, often for hours a day, and monitor their performance rigorously—but the same can be said for many other professions, including musicians, chefs, and public speakers.

In medicine, we call seeing patients every day “practice.” But we aren’t practicing if we aren’t getting feedback and improving—we are just performing. None of us can hope to be the Michael Phelps, Yo-Yo Ma, or Grant Achatz of medicine that our patients deserve us to be without real practice.

Human Dx builds on the science of learning by enabling physicians and students to quickly test and get feedback on their clinical reasoning skills. This is done both by receiving input on their own cases as well as giving input on other contributors’ cases to compare their thinking with physicians and students from around the world. Our goal is for Global Morning Report to become the daily personalized workout schedule for doctors everywhere. What I’d like to see is that rigorous practice and pursuit of excellence in clinical reasoning, diagnosis, and management becoming a core part of the physician experience.

Q: What kind of feedback are you hearing from participants?

A: Doctors love it! Many tell us this is their daily Sudoku or crossword that they do every morning to wake their minds up on the way to work. And our numbers show it: The average active participant contributes five cases per week. And today, that’s without any CME credit or other clear reward other than learning and enjoyment.

That said, we have much to improve, and we aren’t resting on our laurels. The whole ethos of the Human Diagnosis Project is created and led by the global medical community. We are lucky to have an incredible community of physicians and trainees globally who keep us moving forward each day.

Q: Why was a partnership with SHM appealing for this project?

A: At Human Dx, we look at ourselves simply as enablers. We are making it possible for the global medical community to come together and build something important for current and future generations. As such, we want to work with the best institutions in medicine to take their expertise, content, and community and make them more available to the world. As one of the largest, fastest growing, and innovative communities in medicine, SHM is an ideal partner, and we count ourselves very fortunate to have your support.

Q: How can hospitalists participate?

A: Start contributing cases! Not every doctor is interested in medical education, technology, or policy, but every physician I know has great cases and insights to share with the world. My hope is that for physicians and medical students, contributing to Human Dx is their 10 minutes a day to be a part of something greater than themselves, allowing them to share their insights with humankind, build a resource for current and future generations, and, in doing so, renew the reasons that brought them to medicine in the first place and find joy in clinical practice. TH

Join the movement today and solve a case now at www.humandx.org/shm.

Clinical Question: How often are goals of care (GOC) discussed during hospitalization of long-term care residents, and what patient characteristics make this more likely to occur?

Background: GOC discussions during hospitalization have the potential to better align patient wishes with care received and to reduce unwanted care. Previous studies have examined barriers to GOC discussions, but less is known about factors associated with GOC discussions occurring and the outcomes of these discussions.

Study Design: Retrospective chart review.

Setting: Two academic hospitals in Toronto.

Synopsis: In the review, 665 hospitalized patients during a one-year period were identified as being >65 years old and from a long-term care facility. Of the 665 patients, a random sampling of 200 unique patients was reviewed. Of these, 37.5% had a documented GOC discussion. Lower Glasgow Coma Scale scores and higher respiratory rates were correlated with a higher incidence of GOC discussions. Patients with GOC discussions had higher rates of no resuscitation and comfort care orders; these patients also had higher odds of in-hospital death and one-year mortality. Of patients that had a change in their GOC, 74% did not have this change reflected in the discharge summary.

Although this study is a retrospective review and limited to two Canadian teaching hospitals, there is likely an opportunity for hospitalists to more frequently discuss and document GOC in hospitalized long-term care patients.

Bottom Line: In hospitalized long-term care patients, GOC are infrequently discussed and documented. Frequency of discussions is correlated with illness severity.

Citation: Wong HJ, Wang J, Grinman M, Wu RC. Goals of care discussions among hospitalized long-term care residents: predictors and associated outcomes of care [published online ahead of print July 21, 2016]. J Hosp Med.

Short Take

Sleep-Promoting Interventions Improve Sleep in Hospitalized Patients

A non-blinded, quasi-randomized pilot study of 112 patients demonstrated that sleep-promoting interventions, including education and environmental control to minimize sleep disruption, improved total nighttime sleep time as well as qualitative measures of sleep.

Citation: Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study aiming to support sleep quality and duration during hospitalizations. J Hosp Med. 2016;11(7):467-472.

Clinical Question: How often are goals of care (GOC) discussed during hospitalization of long-term care residents, and what patient characteristics make this more likely to occur?

Background: GOC discussions during hospitalization have the potential to better align patient wishes with care received and to reduce unwanted care. Previous studies have examined barriers to GOC discussions, but less is known about factors associated with GOC discussions occurring and the outcomes of these discussions.

Study Design: Retrospective chart review.

Setting: Two academic hospitals in Toronto.

Synopsis: In the review, 665 hospitalized patients during a one-year period were identified as being >65 years old and from a long-term care facility. Of the 665 patients, a random sampling of 200 unique patients was reviewed. Of these, 37.5% had a documented GOC discussion. Lower Glasgow Coma Scale scores and higher respiratory rates were correlated with a higher incidence of GOC discussions. Patients with GOC discussions had higher rates of no resuscitation and comfort care orders; these patients also had higher odds of in-hospital death and one-year mortality. Of patients that had a change in their GOC, 74% did not have this change reflected in the discharge summary.

Although this study is a retrospective review and limited to two Canadian teaching hospitals, there is likely an opportunity for hospitalists to more frequently discuss and document GOC in hospitalized long-term care patients.

Bottom Line: In hospitalized long-term care patients, GOC are infrequently discussed and documented. Frequency of discussions is correlated with illness severity.

Citation: Wong HJ, Wang J, Grinman M, Wu RC. Goals of care discussions among hospitalized long-term care residents: predictors and associated outcomes of care [published online ahead of print July 21, 2016]. J Hosp Med.

Short Take

Sleep-Promoting Interventions Improve Sleep in Hospitalized Patients

A non-blinded, quasi-randomized pilot study of 112 patients demonstrated that sleep-promoting interventions, including education and environmental control to minimize sleep disruption, improved total nighttime sleep time as well as qualitative measures of sleep.

Citation: Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study aiming to support sleep quality and duration during hospitalizations. J Hosp Med. 2016;11(7):467-472.

Clinical Question: How often are goals of care (GOC) discussed during hospitalization of long-term care residents, and what patient characteristics make this more likely to occur?

Background: GOC discussions during hospitalization have the potential to better align patient wishes with care received and to reduce unwanted care. Previous studies have examined barriers to GOC discussions, but less is known about factors associated with GOC discussions occurring and the outcomes of these discussions.

Study Design: Retrospective chart review.

Setting: Two academic hospitals in Toronto.

Synopsis: In the review, 665 hospitalized patients during a one-year period were identified as being >65 years old and from a long-term care facility. Of the 665 patients, a random sampling of 200 unique patients was reviewed. Of these, 37.5% had a documented GOC discussion. Lower Glasgow Coma Scale scores and higher respiratory rates were correlated with a higher incidence of GOC discussions. Patients with GOC discussions had higher rates of no resuscitation and comfort care orders; these patients also had higher odds of in-hospital death and one-year mortality. Of patients that had a change in their GOC, 74% did not have this change reflected in the discharge summary.

Although this study is a retrospective review and limited to two Canadian teaching hospitals, there is likely an opportunity for hospitalists to more frequently discuss and document GOC in hospitalized long-term care patients.

Bottom Line: In hospitalized long-term care patients, GOC are infrequently discussed and documented. Frequency of discussions is correlated with illness severity.

Citation: Wong HJ, Wang J, Grinman M, Wu RC. Goals of care discussions among hospitalized long-term care residents: predictors and associated outcomes of care [published online ahead of print July 21, 2016]. J Hosp Med.

Short Take

Sleep-Promoting Interventions Improve Sleep in Hospitalized Patients

A non-blinded, quasi-randomized pilot study of 112 patients demonstrated that sleep-promoting interventions, including education and environmental control to minimize sleep disruption, improved total nighttime sleep time as well as qualitative measures of sleep.

Citation: Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study aiming to support sleep quality and duration during hospitalizations. J Hosp Med. 2016;11(7):467-472.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

LOS ANGELES – Instead of replacing the Systemic Inflammatory Response Syndrome (SIRS) score with the new quick Sequential Organ Failure Assessment (qSOFA) score to identify severe sepsis patients, it might be best to use both, according to two studies presented at the American College of Chest Physicians annual meeting.

The gold standard 3rd International Consensus Definitions for Sepsis and Septic Shock Task Force recently introduced qSOFA to replace SIRS, in part because SIRS is too sensitive. With criteria that include a temperature above 38° C; a heart rate above 90 bpm, and a respiratory rate above 20 breaths per minute, it’s possible to score positive on SIRS by walking up a flight of stairs, audience members at the study presentations noted.

The first study at the meeting session – a prospective cohort of 152 patients scored by both systems within 8 hours of ICU admission at the New York–Presbyterian Hospital – found that qSOFA was slightly better at predicting in-hospital mortality and ICU-free days, but no better than SIRS at predicting ventilator- or organ failure–free days.

However, of the 36% of patients (55) who met only one of the three qSOFA criteria - a respiratory rate of 22 breaths per minute, altered mental status, or a systolic blood pressure of 100 mg Hg or less - 6% (3) died in the hospital. Of those patients, two-thirds (2) were SIRS positive, meaning that they met two or more SIRS criteria.

“Having a borderline qSOFA of 1 point, which is considered negative, with the addition of having SIRS criteria, should raise concerns that patients need further evaluation. SIRS criteria should not be [entirely] discarded” in favor of qSOFA, said lead investigator Eli Finkelsztein, MD, of the New York–Presbyterian Hospital in New York City

The second study – a review of 6,811 severe sepsis/septic shock patients scored by both systems within 3 hours of emergency department admission at the University of Kansas Hospital emergency department in Kansas City – found that the two scores performed largely the same when it came to predicting ICU admission and 30-day mortality, but that people who met two or more criteria in both systems were of special concern.

Twenty-five percent of patients (1,713) scored 2 or more on both SIRS and qSOFA. These patients were more likely to be admitted to the ICU and be readmitted to the hospital after a month, compared with those patients who were positive in only one scoring system or negative in both. Additional factors associated with these patients were that they had the longest ICU and hospital lengths of stay. Two hundred (12%) of these patients scoring 2 or more on both SIRS and qSOFA died within 30 days.

“SIRS criteria continue to be more sensitive at identifying severe sepsis, but they are equally as accurate [as qSOFA criteria] at predicting adverse patient outcomes,” said lead investigator and Kansas University medical student Amanda Deis.

SIRS and qSOFA take only a few seconds to assess at the bedside. Using both builds “a clinical picture,” she said.

There was no industry funding for the work, and the investigators had no relevant financial disclosures.
 

[email protected]

LOS ANGELES – Instead of replacing the Systemic Inflammatory Response Syndrome (SIRS) score with the new quick Sequential Organ Failure Assessment (qSOFA) score to identify severe sepsis patients, it might be best to use both, according to two studies presented at the American College of Chest Physicians annual meeting.

The gold standard 3rd International Consensus Definitions for Sepsis and Septic Shock Task Force recently introduced qSOFA to replace SIRS, in part because SIRS is too sensitive. With criteria that include a temperature above 38° C; a heart rate above 90 bpm, and a respiratory rate above 20 breaths per minute, it’s possible to score positive on SIRS by walking up a flight of stairs, audience members at the study presentations noted.

The first study at the meeting session – a prospective cohort of 152 patients scored by both systems within 8 hours of ICU admission at the New York–Presbyterian Hospital – found that qSOFA was slightly better at predicting in-hospital mortality and ICU-free days, but no better than SIRS at predicting ventilator- or organ failure–free days.

However, of the 36% of patients (55) who met only one of the three qSOFA criteria - a respiratory rate of 22 breaths per minute, altered mental status, or a systolic blood pressure of 100 mg Hg or less - 6% (3) died in the hospital. Of those patients, two-thirds (2) were SIRS positive, meaning that they met two or more SIRS criteria.

“Having a borderline qSOFA of 1 point, which is considered negative, with the addition of having SIRS criteria, should raise concerns that patients need further evaluation. SIRS criteria should not be [entirely] discarded” in favor of qSOFA, said lead investigator Eli Finkelsztein, MD, of the New York–Presbyterian Hospital in New York City

The second study – a review of 6,811 severe sepsis/septic shock patients scored by both systems within 3 hours of emergency department admission at the University of Kansas Hospital emergency department in Kansas City – found that the two scores performed largely the same when it came to predicting ICU admission and 30-day mortality, but that people who met two or more criteria in both systems were of special concern.

Twenty-five percent of patients (1,713) scored 2 or more on both SIRS and qSOFA. These patients were more likely to be admitted to the ICU and be readmitted to the hospital after a month, compared with those patients who were positive in only one scoring system or negative in both. Additional factors associated with these patients were that they had the longest ICU and hospital lengths of stay. Two hundred (12%) of these patients scoring 2 or more on both SIRS and qSOFA died within 30 days.

“SIRS criteria continue to be more sensitive at identifying severe sepsis, but they are equally as accurate [as qSOFA criteria] at predicting adverse patient outcomes,” said lead investigator and Kansas University medical student Amanda Deis.

SIRS and qSOFA take only a few seconds to assess at the bedside. Using both builds “a clinical picture,” she said.

There was no industry funding for the work, and the investigators had no relevant financial disclosures.
 

[email protected]

LOS ANGELES – Instead of replacing the Systemic Inflammatory Response Syndrome (SIRS) score with the new quick Sequential Organ Failure Assessment (qSOFA) score to identify severe sepsis patients, it might be best to use both, according to two studies presented at the American College of Chest Physicians annual meeting.

The gold standard 3rd International Consensus Definitions for Sepsis and Septic Shock Task Force recently introduced qSOFA to replace SIRS, in part because SIRS is too sensitive. With criteria that include a temperature above 38° C; a heart rate above 90 bpm, and a respiratory rate above 20 breaths per minute, it’s possible to score positive on SIRS by walking up a flight of stairs, audience members at the study presentations noted.

The first study at the meeting session – a prospective cohort of 152 patients scored by both systems within 8 hours of ICU admission at the New York–Presbyterian Hospital – found that qSOFA was slightly better at predicting in-hospital mortality and ICU-free days, but no better than SIRS at predicting ventilator- or organ failure–free days.

However, of the 36% of patients (55) who met only one of the three qSOFA criteria - a respiratory rate of 22 breaths per minute, altered mental status, or a systolic blood pressure of 100 mg Hg or less - 6% (3) died in the hospital. Of those patients, two-thirds (2) were SIRS positive, meaning that they met two or more SIRS criteria.

“Having a borderline qSOFA of 1 point, which is considered negative, with the addition of having SIRS criteria, should raise concerns that patients need further evaluation. SIRS criteria should not be [entirely] discarded” in favor of qSOFA, said lead investigator Eli Finkelsztein, MD, of the New York–Presbyterian Hospital in New York City

The second study – a review of 6,811 severe sepsis/septic shock patients scored by both systems within 3 hours of emergency department admission at the University of Kansas Hospital emergency department in Kansas City – found that the two scores performed largely the same when it came to predicting ICU admission and 30-day mortality, but that people who met two or more criteria in both systems were of special concern.

Twenty-five percent of patients (1,713) scored 2 or more on both SIRS and qSOFA. These patients were more likely to be admitted to the ICU and be readmitted to the hospital after a month, compared with those patients who were positive in only one scoring system or negative in both. Additional factors associated with these patients were that they had the longest ICU and hospital lengths of stay. Two hundred (12%) of these patients scoring 2 or more on both SIRS and qSOFA died within 30 days.

“SIRS criteria continue to be more sensitive at identifying severe sepsis, but they are equally as accurate [as qSOFA criteria] at predicting adverse patient outcomes,” said lead investigator and Kansas University medical student Amanda Deis.

SIRS and qSOFA take only a few seconds to assess at the bedside. Using both builds “a clinical picture,” she said.

There was no industry funding for the work, and the investigators had no relevant financial disclosures.
 

[email protected]

Rates of 30-day readmissions, which are both common and difficult to predict, are of major concern to hospitalists.

“Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types,” according to a recent article in the Journal of Hospital Medicine. “One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions.”

This fact led the authors to perform a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) could predict 30-day hospital readmission. The 36 variables in the CDA algorithm included age, radiologic agents, and temperature. The retrospective study assessed 3,015 patients admitted to eight general medicine units for all-cause 30-day readmission. Of these, 1,141 patients triggered a CDA, and they were significantly more likely to have a 30-day readmission compared to those who did not trigger a CDA (23.6% versus 15.9%).

The researchers concluded that readily identifiable clinical variables can be identified that predict 30-day readmission.

“It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be ‘fair’ to institutions that care for more seriously ill patients,” they write. “The development of an accurate real-time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death and post-discharge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations.”

Reference

1. Micek ST, Samant M, Bailey T, et al. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission [published online ahead of print June 3, 2016]. J Hosp Med. doi:10.1002/jhm.2617.

Quick Byte

The Cost of Vaccine Avoidance

Many Americans avoid their recommended vaccines: For example, the Centers for Disease Control and Prevention (CDC) reports that only 42% of U.S. adults age 18 or older received the flu vaccine during the 2015–2016 flu season. A study recently released online by Health Affairs calculated the annual cost of the diseases associated with 10 vaccines the CDC recommends for adults. In 2015, that economic burden was $8.95 billion. A full 80% of that—$7.1 billion—was attributed to unvaccinated people.

Reference

1. The cost of US adult vaccine avoidance: $8.95 billion in 2015. Health Affairs website. Accessed October 17, 2016

Rates of 30-day readmissions, which are both common and difficult to predict, are of major concern to hospitalists.

“Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types,” according to a recent article in the Journal of Hospital Medicine. “One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions.”

This fact led the authors to perform a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) could predict 30-day hospital readmission. The 36 variables in the CDA algorithm included age, radiologic agents, and temperature. The retrospective study assessed 3,015 patients admitted to eight general medicine units for all-cause 30-day readmission. Of these, 1,141 patients triggered a CDA, and they were significantly more likely to have a 30-day readmission compared to those who did not trigger a CDA (23.6% versus 15.9%).

The researchers concluded that readily identifiable clinical variables can be identified that predict 30-day readmission.

“It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be ‘fair’ to institutions that care for more seriously ill patients,” they write. “The development of an accurate real-time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death and post-discharge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations.”

Reference

1. Micek ST, Samant M, Bailey T, et al. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission [published online ahead of print June 3, 2016]. J Hosp Med. doi:10.1002/jhm.2617.

Quick Byte

The Cost of Vaccine Avoidance

Many Americans avoid their recommended vaccines: For example, the Centers for Disease Control and Prevention (CDC) reports that only 42% of U.S. adults age 18 or older received the flu vaccine during the 2015–2016 flu season. A study recently released online by Health Affairs calculated the annual cost of the diseases associated with 10 vaccines the CDC recommends for adults. In 2015, that economic burden was $8.95 billion. A full 80% of that—$7.1 billion—was attributed to unvaccinated people.

Reference

1. The cost of US adult vaccine avoidance: $8.95 billion in 2015. Health Affairs website. Accessed October 17, 2016

Rates of 30-day readmissions, which are both common and difficult to predict, are of major concern to hospitalists.

“Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types,” according to a recent article in the Journal of Hospital Medicine. “One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions.”

This fact led the authors to perform a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) could predict 30-day hospital readmission. The 36 variables in the CDA algorithm included age, radiologic agents, and temperature. The retrospective study assessed 3,015 patients admitted to eight general medicine units for all-cause 30-day readmission. Of these, 1,141 patients triggered a CDA, and they were significantly more likely to have a 30-day readmission compared to those who did not trigger a CDA (23.6% versus 15.9%).

The researchers concluded that readily identifiable clinical variables can be identified that predict 30-day readmission.

“It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be ‘fair’ to institutions that care for more seriously ill patients,” they write. “The development of an accurate real-time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death and post-discharge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations.”

Reference

1. Micek ST, Samant M, Bailey T, et al. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission [published online ahead of print June 3, 2016]. J Hosp Med. doi:10.1002/jhm.2617.

Quick Byte

The Cost of Vaccine Avoidance

Many Americans avoid their recommended vaccines: For example, the Centers for Disease Control and Prevention (CDC) reports that only 42% of U.S. adults age 18 or older received the flu vaccine during the 2015–2016 flu season. A study recently released online by Health Affairs calculated the annual cost of the diseases associated with 10 vaccines the CDC recommends for adults. In 2015, that economic burden was $8.95 billion. A full 80% of that—$7.1 billion—was attributed to unvaccinated people.

Reference

1. The cost of US adult vaccine avoidance: $8.95 billion in 2015. Health Affairs website. Accessed October 17, 2016

Twenty percent of Americans live in areas where there are shortages of physicians, according to a policy brief in Health Affairs. Some analysts believe the answer to this problem is telehealth, which they say could also save the healthcare industry some $4.28 billion annually.

While the Affordable Care Act signaled a move toward telehealth development at the federal level (through Medicare), states still largely govern coverage of telehealth services by Medicaid or private insurers.

“Currently there is no uniform legal approach to telehealth, and this continues to be a major challenge in its provision. In particular, concerns about reimbursements, for both private insurers and public programs such as Medicaid, continue to limit the implementation and use of telehealth services,” according to the brief.

Now, Congress is considering the Medicare Telehealth Parity Act, intended to modernize the way Medicare reimburses telehealth services and to expand locations and coverage. To enjoy the benefits of telehealth services, states are likely to move toward full-parity laws for the services, the brief notes.

“Without parity, there are limited incentives for the development of telehealth or for providers to move toward telehealth services,” according to the brief. “If there are no incentives to use telehealth, then providers will continue to focus on in-person care, which will keep healthcare costs high, continue to create access issues, and possibly provide lesser standards of care for chronic disease patients who benefit from remote monitoring.”

Reference

1. Yang T. Telehealth parity laws. Health Affairs Website. Accessed October 17, 2016.

Twenty percent of Americans live in areas where there are shortages of physicians, according to a policy brief in Health Affairs. Some analysts believe the answer to this problem is telehealth, which they say could also save the healthcare industry some $4.28 billion annually.

While the Affordable Care Act signaled a move toward telehealth development at the federal level (through Medicare), states still largely govern coverage of telehealth services by Medicaid or private insurers.

“Currently there is no uniform legal approach to telehealth, and this continues to be a major challenge in its provision. In particular, concerns about reimbursements, for both private insurers and public programs such as Medicaid, continue to limit the implementation and use of telehealth services,” according to the brief.

Now, Congress is considering the Medicare Telehealth Parity Act, intended to modernize the way Medicare reimburses telehealth services and to expand locations and coverage. To enjoy the benefits of telehealth services, states are likely to move toward full-parity laws for the services, the brief notes.

“Without parity, there are limited incentives for the development of telehealth or for providers to move toward telehealth services,” according to the brief. “If there are no incentives to use telehealth, then providers will continue to focus on in-person care, which will keep healthcare costs high, continue to create access issues, and possibly provide lesser standards of care for chronic disease patients who benefit from remote monitoring.”

Reference

1. Yang T. Telehealth parity laws. Health Affairs Website. Accessed October 17, 2016.

Twenty percent of Americans live in areas where there are shortages of physicians, according to a policy brief in Health Affairs. Some analysts believe the answer to this problem is telehealth, which they say could also save the healthcare industry some $4.28 billion annually.

While the Affordable Care Act signaled a move toward telehealth development at the federal level (through Medicare), states still largely govern coverage of telehealth services by Medicaid or private insurers.

“Currently there is no uniform legal approach to telehealth, and this continues to be a major challenge in its provision. In particular, concerns about reimbursements, for both private insurers and public programs such as Medicaid, continue to limit the implementation and use of telehealth services,” according to the brief.

Now, Congress is considering the Medicare Telehealth Parity Act, intended to modernize the way Medicare reimburses telehealth services and to expand locations and coverage. To enjoy the benefits of telehealth services, states are likely to move toward full-parity laws for the services, the brief notes.

“Without parity, there are limited incentives for the development of telehealth or for providers to move toward telehealth services,” according to the brief. “If there are no incentives to use telehealth, then providers will continue to focus on in-person care, which will keep healthcare costs high, continue to create access issues, and possibly provide lesser standards of care for chronic disease patients who benefit from remote monitoring.”

Reference

1. Yang T. Telehealth parity laws. Health Affairs Website. Accessed October 17, 2016.

As far back as 1983 —13 years before the birth of HM—Medicare created what was then called an “inpatient prospective payment system,” which essentially let Medicare pay a fixed amount for the entirety of a hospital stay, based on diagnosis. Then in 1991, the Centers for Medicare & Medicaid Services (CMS) introduced one payment for coronary artery bypass graft surgery, and even included 90-day readmission in the check.

Fast forward to the past 10 years when accountable care organizations (ACOs) and value-based purchasing (VBP) have been the focus of HM executives looking to take the lead in how to make bundled payments work for them.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMS’s Center for Medicare & Medicaid Innovation (CMMI) in 2011 and is now compiling its first data sets for the next frontier of payments for episodic care.

For rank-and-file hospitalists who have felt inundated by the regulations and promised payment reforms from ACOs and VBPs, why is this program so important?

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC The Hospitalist Company. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“This model, the bundled model, gives us the flexibility, scale and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

BPCI might be a game-changer for HM because it’s the first of the bundled-payment initiatives that truly falls direct to the care provided by hospitalists. In short, the plan covers 48 defined episodes of care and would parse out payments for those episodes in a holistic—and some say more appropriate—way. Currently, a hospitalist would get paid for a patient’s stay in the hospital and a primary-care physician (PCP) could be paid for some follow-up. If the patient ends up back in the hospital quickly, the hospitalist could get paid again and, upon discharge, a PCP could, too.

But under BPCI, pay would be determined based on the episode of care. The details of who gets paid what and the rules that apply are all likely to evolve, of course, but it’s hoped the basic premise of bundled payments would lower the overall cost of healthcare.

How It Works

Under the Patient Protection and Affordable Care Act (ACA) of 2009, it was mandated that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association.

The program has now ramped up to include more than 650 participating organization, not including thousands of physicians that then partner with those groups, over four models. The initiative covers defined episodes of care, both medical and surgical, that begin at the time of inpatient admission and stretch 30, 60 or 90 days post-discharge.

And hospitalists are poised to take the lead on how payment models, especially bundled payments, are shaped over the next few years, says John Nelson, MD, MHM, a co-founder and past president of SHM and and principal in Nelson Flores Hospital Medicine Consultants in Bellevue, Wash. Nelson says his consulting firm has seen an uptick in calls over the past two years dealing with alternative payment models (APMs).

“Hospitalists find themselves at a vitally important nexus of performance and success on new payment models,” he adds.

Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners in Darien, Conn., agrees that BPCI and future iterations of bundled payment programs “are likely to be a potent driver of an evolving hospitalist specialty.” His hypothesis is that APMs such as BPCI are an important way for Medicare to reach its stated goal of having 50% of its fee-for-service payments running through APMs by the end of 2018. To further entice that process, physicians who document at least 25% of their revenue as coming through APMs will get a 5% bonus.

“The stakes are high now,” says Dr. Whitcomb, a past SHM president whose employer is an Awardee Convener in the BPCI initiative, meaning it administers the program. “Medicare [has] laid out the

course for the next two and a half, three years and beyond… It will be crucial for hospitalists to have a path to participate broadly in APMs..”

Dr. Whitcomb says BPCI is the program that should excite hospitalists most because it is more applicable to them moving forward than ACOs, heralded by many healthcare executives several years ago as the future of payment reform.

“With a focus on ambulatory care, ACOs have not broadly involved hospitalists,” he says. “If you look at the State of Hospital Medicine surveys, you look at how many hospitalists are meaningfully working at a system level on ACOs and committees and so forth to improve the performance of the ACO, and it’s very low.”

In fact, just 13.9% of HM groups serving adults only had formed or were participating in a functioning ACO, according to SHM’s 2014 State of Hospital Medicine report. Another 6% were in the process of forming or participating, the paper reported.

“ACOs have not yet widely worked alongside hospitalist teams to optimize where patients go after hospitalization, which is arguably the most important way to deal with post-acute-care utilization” Dr. Whitcomb adds. “whereas nearly all hospitalists working in bundle payments are focusing on a ‘high-value’ transition out of the hospital.”

Improving Care

While BPCI is focused on payment structure, the program could breed process improvements as well as improve care, says hospitalist Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality.

“In addition to assessing the quality of patient outcomes and patient experience, CMS is also monitoring for unintended consequences, including whether there is an increase in the number of specific clinical episodes [such as specific elective surgeries] that would not have been expected in the absence of BPCI,” Dr. Conway says. “CMS can audit and intervene if it detects unintended negative consequences for beneficiaries.”

Dr. Whitcomb says two main ways that hospitalists can use BPCI to calculate value is by having better metrics on post-acute facility utilization and reduced readmission.

Immediate past SHM President Robert Harrington Jr., MD, SFHM, says that BPCI is a major stepping stone to merging quality and payment, along the lines of using Physician Quality Reporting System (PQRS) data in the value-based payment modifier.

“CMS is saying to all of us in the provider world, ‘We want to get out of the business of unit economics, and we want to start paying for episodes of care and providers should be at risk for quality outcomes,” he says. “BPCI, to me, is one of the rungs in the ladder.”

Dr. Harrington, chief medical officer at Reliant Post-Acute Care Solutions in Atlanta, says that the program’s inclusion of acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together is what differentiates it from past attempts at payment reform.

“Population health is sort of where this is headed,” he adds. “You sit in a CFO seat at a hospital or healthcare system right now, and five years ago, they’d buy an MRI machine and they wanted throughput through that MRI machine and they wanted as many people run through that MRI machine in the fee-for-service world as they could get to go through that machine. Nowadays, you start to look at it from a population health standpoint and the CFO is going to say to you, ‘I don’t want anybody going through that MRI machine unless they have to.’

“So it’s a total reversal of perspective when hospitals either become joined at the hip with the payors or become the payors and they start taking risk on population health and I think BPCI is one way that Medicare has allowed all of us to test the waters and get comfortable with that.”

Getting Involved

Dr. Weiner is aware that some hospitalists are nervous about bundled payments because their reimbursement is, in part based on care provided outside of their control. Take a surgical procedure where a hospitalist managing the post-surgery care is left to deal with any potential mistakes made. Or the process works fine until there is poor management by ambulatory care once the patient is discharged.

“That is the reason this program exists,” he says. “It poses the question, who is going to be accountable for the care outside of the traditional site of care that providers have been practicing in, your traditional boundaries? I would argue that physicians are more or are just as valuable as any other segment of the healthcare system in managing the transitions of care and in managing the gaps in the system.”

Given how HM has moved into post-discharge care via SNFs and other post-acute care facilities in recent years, Dr. Weiner says that while hospitalists can’t actually deliver all of the care in an “episode,” they can shepherd that process.

Hospitalists “have control over where the patient goes after they leave the acute-care facility, for example,” he says. “They write the orders on what level of care is needed, and they should have the intimate knowledge about what’s available in their community to ensure the patient gets the best care possible. As long as they have the accountability and the power to direct care, then they have the ability to negotiate and recommend care that is best for the patient, so they can select the better facilities in the community, the better agencies in the community, the better resources in the community to ensure that there is better care once the patient leaves the hospital.”

Dr. Conway suggests HM practitioners view BPCI as a model based on “quality and value.” He says early participants helped define clinical episodes, length of episode, and risk track, making the program better suited to address the actual needs of hospitalists.

“I would encourage hospital medicine physicians and care teams to view bundled payment models as an opportunity for them and their patients for better care and smarter spending,” he adds. “CMS continues to explore ways to pay for value and not just volume. Many of the organizations that are participating in BPCI have partnered with their physician communities and established gainsharing agreement. …Most importantly, this model focuses on care coordination for patients across episodes of care.

And that’s the key for Dr. Weiner.

Hospitalists who embrace BPCI can shape it as the predominant inpatient funding model for hospitals over the next five or 10 years. HM administrators and practitioners who don’t seize the opportunity to flesh out the program tacitly cede control to people outside the hospital who may not tailor the program nearly as well, he says.

“Those who have accountability in the end, the systems, the people, the entities, the providers that have the ability, the accountability for it will ultimately design it,” Dr. Weiner adds. “I think physicians, especially hospitalists, should be at that table. We should play an active role in designing the system.” TH

Richard Quinn is a freelance writer in New Jersey.

The ABCs of $$$s

Hospitalists whoaren’t in leadership, administrative or committee positions may not be familiar with the latest round of alphabet soup that is tied to payment reform and Medicare’s announced push to have 50% of its payments not by fee-for-service by 2018. Here are the most important ones:

• APM: Alternative payment models. The catch-all phrase for a variety of programs and initiatives that are outside the traditional fee-for-service model.
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015. The act ended the hated sustainable growth rate (SGR) formula and combined CMS’s existing quality reporting programs under one system.
• MIPS: Merit-Based Incentive Payment System. The new program combines parts of the Physician Quality Reporting System (PQRS), the value modifier (VM, or value-based payment modifier/VBPM), and the Medicare electronic health record (EHR) incentive program into a single program.

Source: Centers for Medicare & Medicaid Services

—By Richard Quinn

As far back as 1983 —13 years before the birth of HM—Medicare created what was then called an “inpatient prospective payment system,” which essentially let Medicare pay a fixed amount for the entirety of a hospital stay, based on diagnosis. Then in 1991, the Centers for Medicare & Medicaid Services (CMS) introduced one payment for coronary artery bypass graft surgery, and even included 90-day readmission in the check.

Fast forward to the past 10 years when accountable care organizations (ACOs) and value-based purchasing (VBP) have been the focus of HM executives looking to take the lead in how to make bundled payments work for them.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMS’s Center for Medicare & Medicaid Innovation (CMMI) in 2011 and is now compiling its first data sets for the next frontier of payments for episodic care.

For rank-and-file hospitalists who have felt inundated by the regulations and promised payment reforms from ACOs and VBPs, why is this program so important?

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC The Hospitalist Company. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“This model, the bundled model, gives us the flexibility, scale and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

BPCI might be a game-changer for HM because it’s the first of the bundled-payment initiatives that truly falls direct to the care provided by hospitalists. In short, the plan covers 48 defined episodes of care and would parse out payments for those episodes in a holistic—and some say more appropriate—way. Currently, a hospitalist would get paid for a patient’s stay in the hospital and a primary-care physician (PCP) could be paid for some follow-up. If the patient ends up back in the hospital quickly, the hospitalist could get paid again and, upon discharge, a PCP could, too.

But under BPCI, pay would be determined based on the episode of care. The details of who gets paid what and the rules that apply are all likely to evolve, of course, but it’s hoped the basic premise of bundled payments would lower the overall cost of healthcare.

How It Works

Under the Patient Protection and Affordable Care Act (ACA) of 2009, it was mandated that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association.

The program has now ramped up to include more than 650 participating organization, not including thousands of physicians that then partner with those groups, over four models. The initiative covers defined episodes of care, both medical and surgical, that begin at the time of inpatient admission and stretch 30, 60 or 90 days post-discharge.

And hospitalists are poised to take the lead on how payment models, especially bundled payments, are shaped over the next few years, says John Nelson, MD, MHM, a co-founder and past president of SHM and and principal in Nelson Flores Hospital Medicine Consultants in Bellevue, Wash. Nelson says his consulting firm has seen an uptick in calls over the past two years dealing with alternative payment models (APMs).

“Hospitalists find themselves at a vitally important nexus of performance and success on new payment models,” he adds.

Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners in Darien, Conn., agrees that BPCI and future iterations of bundled payment programs “are likely to be a potent driver of an evolving hospitalist specialty.” His hypothesis is that APMs such as BPCI are an important way for Medicare to reach its stated goal of having 50% of its fee-for-service payments running through APMs by the end of 2018. To further entice that process, physicians who document at least 25% of their revenue as coming through APMs will get a 5% bonus.

“The stakes are high now,” says Dr. Whitcomb, a past SHM president whose employer is an Awardee Convener in the BPCI initiative, meaning it administers the program. “Medicare [has] laid out the

course for the next two and a half, three years and beyond… It will be crucial for hospitalists to have a path to participate broadly in APMs..”

Dr. Whitcomb says BPCI is the program that should excite hospitalists most because it is more applicable to them moving forward than ACOs, heralded by many healthcare executives several years ago as the future of payment reform.

“With a focus on ambulatory care, ACOs have not broadly involved hospitalists,” he says. “If you look at the State of Hospital Medicine surveys, you look at how many hospitalists are meaningfully working at a system level on ACOs and committees and so forth to improve the performance of the ACO, and it’s very low.”

In fact, just 13.9% of HM groups serving adults only had formed or were participating in a functioning ACO, according to SHM’s 2014 State of Hospital Medicine report. Another 6% were in the process of forming or participating, the paper reported.

“ACOs have not yet widely worked alongside hospitalist teams to optimize where patients go after hospitalization, which is arguably the most important way to deal with post-acute-care utilization” Dr. Whitcomb adds. “whereas nearly all hospitalists working in bundle payments are focusing on a ‘high-value’ transition out of the hospital.”

Improving Care

While BPCI is focused on payment structure, the program could breed process improvements as well as improve care, says hospitalist Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality.

“In addition to assessing the quality of patient outcomes and patient experience, CMS is also monitoring for unintended consequences, including whether there is an increase in the number of specific clinical episodes [such as specific elective surgeries] that would not have been expected in the absence of BPCI,” Dr. Conway says. “CMS can audit and intervene if it detects unintended negative consequences for beneficiaries.”

Dr. Whitcomb says two main ways that hospitalists can use BPCI to calculate value is by having better metrics on post-acute facility utilization and reduced readmission.

Immediate past SHM President Robert Harrington Jr., MD, SFHM, says that BPCI is a major stepping stone to merging quality and payment, along the lines of using Physician Quality Reporting System (PQRS) data in the value-based payment modifier.

“CMS is saying to all of us in the provider world, ‘We want to get out of the business of unit economics, and we want to start paying for episodes of care and providers should be at risk for quality outcomes,” he says. “BPCI, to me, is one of the rungs in the ladder.”

Dr. Harrington, chief medical officer at Reliant Post-Acute Care Solutions in Atlanta, says that the program’s inclusion of acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together is what differentiates it from past attempts at payment reform.

“Population health is sort of where this is headed,” he adds. “You sit in a CFO seat at a hospital or healthcare system right now, and five years ago, they’d buy an MRI machine and they wanted throughput through that MRI machine and they wanted as many people run through that MRI machine in the fee-for-service world as they could get to go through that machine. Nowadays, you start to look at it from a population health standpoint and the CFO is going to say to you, ‘I don’t want anybody going through that MRI machine unless they have to.’

“So it’s a total reversal of perspective when hospitals either become joined at the hip with the payors or become the payors and they start taking risk on population health and I think BPCI is one way that Medicare has allowed all of us to test the waters and get comfortable with that.”

Getting Involved

Dr. Weiner is aware that some hospitalists are nervous about bundled payments because their reimbursement is, in part based on care provided outside of their control. Take a surgical procedure where a hospitalist managing the post-surgery care is left to deal with any potential mistakes made. Or the process works fine until there is poor management by ambulatory care once the patient is discharged.

“That is the reason this program exists,” he says. “It poses the question, who is going to be accountable for the care outside of the traditional site of care that providers have been practicing in, your traditional boundaries? I would argue that physicians are more or are just as valuable as any other segment of the healthcare system in managing the transitions of care and in managing the gaps in the system.”

Given how HM has moved into post-discharge care via SNFs and other post-acute care facilities in recent years, Dr. Weiner says that while hospitalists can’t actually deliver all of the care in an “episode,” they can shepherd that process.

Hospitalists “have control over where the patient goes after they leave the acute-care facility, for example,” he says. “They write the orders on what level of care is needed, and they should have the intimate knowledge about what’s available in their community to ensure the patient gets the best care possible. As long as they have the accountability and the power to direct care, then they have the ability to negotiate and recommend care that is best for the patient, so they can select the better facilities in the community, the better agencies in the community, the better resources in the community to ensure that there is better care once the patient leaves the hospital.”

Dr. Conway suggests HM practitioners view BPCI as a model based on “quality and value.” He says early participants helped define clinical episodes, length of episode, and risk track, making the program better suited to address the actual needs of hospitalists.

“I would encourage hospital medicine physicians and care teams to view bundled payment models as an opportunity for them and their patients for better care and smarter spending,” he adds. “CMS continues to explore ways to pay for value and not just volume. Many of the organizations that are participating in BPCI have partnered with their physician communities and established gainsharing agreement. …Most importantly, this model focuses on care coordination for patients across episodes of care.

And that’s the key for Dr. Weiner.

Hospitalists who embrace BPCI can shape it as the predominant inpatient funding model for hospitals over the next five or 10 years. HM administrators and practitioners who don’t seize the opportunity to flesh out the program tacitly cede control to people outside the hospital who may not tailor the program nearly as well, he says.

“Those who have accountability in the end, the systems, the people, the entities, the providers that have the ability, the accountability for it will ultimately design it,” Dr. Weiner adds. “I think physicians, especially hospitalists, should be at that table. We should play an active role in designing the system.” TH

Richard Quinn is a freelance writer in New Jersey.

The ABCs of $$$s

Hospitalists whoaren’t in leadership, administrative or committee positions may not be familiar with the latest round of alphabet soup that is tied to payment reform and Medicare’s announced push to have 50% of its payments not by fee-for-service by 2018. Here are the most important ones:

• APM: Alternative payment models. The catch-all phrase for a variety of programs and initiatives that are outside the traditional fee-for-service model.
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015. The act ended the hated sustainable growth rate (SGR) formula and combined CMS’s existing quality reporting programs under one system.
• MIPS: Merit-Based Incentive Payment System. The new program combines parts of the Physician Quality Reporting System (PQRS), the value modifier (VM, or value-based payment modifier/VBPM), and the Medicare electronic health record (EHR) incentive program into a single program.

Source: Centers for Medicare & Medicaid Services

—By Richard Quinn

As far back as 1983 —13 years before the birth of HM—Medicare created what was then called an “inpatient prospective payment system,” which essentially let Medicare pay a fixed amount for the entirety of a hospital stay, based on diagnosis. Then in 1991, the Centers for Medicare & Medicaid Services (CMS) introduced one payment for coronary artery bypass graft surgery, and even included 90-day readmission in the check.

Fast forward to the past 10 years when accountable care organizations (ACOs) and value-based purchasing (VBP) have been the focus of HM executives looking to take the lead in how to make bundled payments work for them.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMS’s Center for Medicare & Medicaid Innovation (CMMI) in 2011 and is now compiling its first data sets for the next frontier of payments for episodic care.

For rank-and-file hospitalists who have felt inundated by the regulations and promised payment reforms from ACOs and VBPs, why is this program so important?

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC The Hospitalist Company. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“This model, the bundled model, gives us the flexibility, scale and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

BPCI might be a game-changer for HM because it’s the first of the bundled-payment initiatives that truly falls direct to the care provided by hospitalists. In short, the plan covers 48 defined episodes of care and would parse out payments for those episodes in a holistic—and some say more appropriate—way. Currently, a hospitalist would get paid for a patient’s stay in the hospital and a primary-care physician (PCP) could be paid for some follow-up. If the patient ends up back in the hospital quickly, the hospitalist could get paid again and, upon discharge, a PCP could, too.

But under BPCI, pay would be determined based on the episode of care. The details of who gets paid what and the rules that apply are all likely to evolve, of course, but it’s hoped the basic premise of bundled payments would lower the overall cost of healthcare.

How It Works

Under the Patient Protection and Affordable Care Act (ACA) of 2009, it was mandated that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association.

The program has now ramped up to include more than 650 participating organization, not including thousands of physicians that then partner with those groups, over four models. The initiative covers defined episodes of care, both medical and surgical, that begin at the time of inpatient admission and stretch 30, 60 or 90 days post-discharge.

And hospitalists are poised to take the lead on how payment models, especially bundled payments, are shaped over the next few years, says John Nelson, MD, MHM, a co-founder and past president of SHM and and principal in Nelson Flores Hospital Medicine Consultants in Bellevue, Wash. Nelson says his consulting firm has seen an uptick in calls over the past two years dealing with alternative payment models (APMs).

“Hospitalists find themselves at a vitally important nexus of performance and success on new payment models,” he adds.

Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners in Darien, Conn., agrees that BPCI and future iterations of bundled payment programs “are likely to be a potent driver of an evolving hospitalist specialty.” His hypothesis is that APMs such as BPCI are an important way for Medicare to reach its stated goal of having 50% of its fee-for-service payments running through APMs by the end of 2018. To further entice that process, physicians who document at least 25% of their revenue as coming through APMs will get a 5% bonus.

“The stakes are high now,” says Dr. Whitcomb, a past SHM president whose employer is an Awardee Convener in the BPCI initiative, meaning it administers the program. “Medicare [has] laid out the

course for the next two and a half, three years and beyond… It will be crucial for hospitalists to have a path to participate broadly in APMs..”

Dr. Whitcomb says BPCI is the program that should excite hospitalists most because it is more applicable to them moving forward than ACOs, heralded by many healthcare executives several years ago as the future of payment reform.

“With a focus on ambulatory care, ACOs have not broadly involved hospitalists,” he says. “If you look at the State of Hospital Medicine surveys, you look at how many hospitalists are meaningfully working at a system level on ACOs and committees and so forth to improve the performance of the ACO, and it’s very low.”

In fact, just 13.9% of HM groups serving adults only had formed or were participating in a functioning ACO, according to SHM’s 2014 State of Hospital Medicine report. Another 6% were in the process of forming or participating, the paper reported.

“ACOs have not yet widely worked alongside hospitalist teams to optimize where patients go after hospitalization, which is arguably the most important way to deal with post-acute-care utilization” Dr. Whitcomb adds. “whereas nearly all hospitalists working in bundle payments are focusing on a ‘high-value’ transition out of the hospital.”

Improving Care

While BPCI is focused on payment structure, the program could breed process improvements as well as improve care, says hospitalist Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality.

“In addition to assessing the quality of patient outcomes and patient experience, CMS is also monitoring for unintended consequences, including whether there is an increase in the number of specific clinical episodes [such as specific elective surgeries] that would not have been expected in the absence of BPCI,” Dr. Conway says. “CMS can audit and intervene if it detects unintended negative consequences for beneficiaries.”

Dr. Whitcomb says two main ways that hospitalists can use BPCI to calculate value is by having better metrics on post-acute facility utilization and reduced readmission.

Immediate past SHM President Robert Harrington Jr., MD, SFHM, says that BPCI is a major stepping stone to merging quality and payment, along the lines of using Physician Quality Reporting System (PQRS) data in the value-based payment modifier.

“CMS is saying to all of us in the provider world, ‘We want to get out of the business of unit economics, and we want to start paying for episodes of care and providers should be at risk for quality outcomes,” he says. “BPCI, to me, is one of the rungs in the ladder.”

Dr. Harrington, chief medical officer at Reliant Post-Acute Care Solutions in Atlanta, says that the program’s inclusion of acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together is what differentiates it from past attempts at payment reform.

“Population health is sort of where this is headed,” he adds. “You sit in a CFO seat at a hospital or healthcare system right now, and five years ago, they’d buy an MRI machine and they wanted throughput through that MRI machine and they wanted as many people run through that MRI machine in the fee-for-service world as they could get to go through that machine. Nowadays, you start to look at it from a population health standpoint and the CFO is going to say to you, ‘I don’t want anybody going through that MRI machine unless they have to.’

“So it’s a total reversal of perspective when hospitals either become joined at the hip with the payors or become the payors and they start taking risk on population health and I think BPCI is one way that Medicare has allowed all of us to test the waters and get comfortable with that.”

Getting Involved

Dr. Weiner is aware that some hospitalists are nervous about bundled payments because their reimbursement is, in part based on care provided outside of their control. Take a surgical procedure where a hospitalist managing the post-surgery care is left to deal with any potential mistakes made. Or the process works fine until there is poor management by ambulatory care once the patient is discharged.

“That is the reason this program exists,” he says. “It poses the question, who is going to be accountable for the care outside of the traditional site of care that providers have been practicing in, your traditional boundaries? I would argue that physicians are more or are just as valuable as any other segment of the healthcare system in managing the transitions of care and in managing the gaps in the system.”

Given how HM has moved into post-discharge care via SNFs and other post-acute care facilities in recent years, Dr. Weiner says that while hospitalists can’t actually deliver all of the care in an “episode,” they can shepherd that process.

Hospitalists “have control over where the patient goes after they leave the acute-care facility, for example,” he says. “They write the orders on what level of care is needed, and they should have the intimate knowledge about what’s available in their community to ensure the patient gets the best care possible. As long as they have the accountability and the power to direct care, then they have the ability to negotiate and recommend care that is best for the patient, so they can select the better facilities in the community, the better agencies in the community, the better resources in the community to ensure that there is better care once the patient leaves the hospital.”

Dr. Conway suggests HM practitioners view BPCI as a model based on “quality and value.” He says early participants helped define clinical episodes, length of episode, and risk track, making the program better suited to address the actual needs of hospitalists.

“I would encourage hospital medicine physicians and care teams to view bundled payment models as an opportunity for them and their patients for better care and smarter spending,” he adds. “CMS continues to explore ways to pay for value and not just volume. Many of the organizations that are participating in BPCI have partnered with their physician communities and established gainsharing agreement. …Most importantly, this model focuses on care coordination for patients across episodes of care.

And that’s the key for Dr. Weiner.

Hospitalists who embrace BPCI can shape it as the predominant inpatient funding model for hospitals over the next five or 10 years. HM administrators and practitioners who don’t seize the opportunity to flesh out the program tacitly cede control to people outside the hospital who may not tailor the program nearly as well, he says.

“Those who have accountability in the end, the systems, the people, the entities, the providers that have the ability, the accountability for it will ultimately design it,” Dr. Weiner adds. “I think physicians, especially hospitalists, should be at that table. We should play an active role in designing the system.” TH

Richard Quinn is a freelance writer in New Jersey.

The ABCs of $$$s

Hospitalists whoaren’t in leadership, administrative or committee positions may not be familiar with the latest round of alphabet soup that is tied to payment reform and Medicare’s announced push to have 50% of its payments not by fee-for-service by 2018. Here are the most important ones:

• APM: Alternative payment models. The catch-all phrase for a variety of programs and initiatives that are outside the traditional fee-for-service model.
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015. The act ended the hated sustainable growth rate (SGR) formula and combined CMS’s existing quality reporting programs under one system.
• MIPS: Merit-Based Incentive Payment System. The new program combines parts of the Physician Quality Reporting System (PQRS), the value modifier (VM, or value-based payment modifier/VBPM), and the Medicare electronic health record (EHR) incentive program into a single program.

Source: Centers for Medicare & Medicaid Services

—By Richard Quinn

SHM is now accepting submissions for the Hospital Medicine 2017 (HM17) Research, Innovations, and Clinical Vignettes (RIV) abstract and poster competition. Seize the opportunity to present your research, innovative ideas, and clinical stories to a national audience at HM17, May 1–4, 2017, in Las Vegas. Learn more by visiting www.hospitalmedicine2017.org.

SHM strongly recommends that you complete your submission well ahead of the deadline of Monday, December 5, 2016. New to SHM? Registration for HM17 includes a complimentary one-year SHM membership. Register online prior to March 6, 2017, to receive the best registration rates.

SHM is now accepting submissions for the Hospital Medicine 2017 (HM17) Research, Innovations, and Clinical Vignettes (RIV) abstract and poster competition. Seize the opportunity to present your research, innovative ideas, and clinical stories to a national audience at HM17, May 1–4, 2017, in Las Vegas. Learn more by visiting www.hospitalmedicine2017.org.

SHM strongly recommends that you complete your submission well ahead of the deadline of Monday, December 5, 2016. New to SHM? Registration for HM17 includes a complimentary one-year SHM membership. Register online prior to March 6, 2017, to receive the best registration rates.

SHM is now accepting submissions for the Hospital Medicine 2017 (HM17) Research, Innovations, and Clinical Vignettes (RIV) abstract and poster competition. Seize the opportunity to present your research, innovative ideas, and clinical stories to a national audience at HM17, May 1–4, 2017, in Las Vegas. Learn more by visiting www.hospitalmedicine2017.org.

SHM strongly recommends that you complete your submission well ahead of the deadline of Monday, December 5, 2016. New to SHM? Registration for HM17 includes a complimentary one-year SHM membership. Register online prior to March 6, 2017, to receive the best registration rates.

The regular decision application is open through November 30, with a decision on or before December 31, 2016. Learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

The regular decision application is open through November 30, with a decision on or before December 31, 2016. Learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

The regular decision application is open through November 30, with a decision on or before December 31, 2016. Learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.