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Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

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Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

---

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

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Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

I first became aware of measuring customer satisfaction when a service manager at a car dealership explained in an upbeat way that I would be getting a survey and that any response by me other than the highest rating would result in significant negative consequences. I can recall being pleased with the service right up to the point the manager tried to extract a promise from me that I would provide “top box” answers.

What started with a car dealership survey has become a near avalanche of surveys from my credit card, bank, airlines, hotels, and other businesses. Each starts by assuring me that it will take only a minute or two to complete the survey, but if I completed every survey sent my way, it would add up to a significant amount of time. So I’ve stopped responding to nearly all of them, not so much as a form of protest but as part of my overall time-management efforts.

I imagine many of our patients see surveys from hospitals and other healthcare providers similarly: just another one to add to the pile. Patients in their 80s and 90s—a significant portion of hospitalist patients—probably interact a lot less with companies that send satisfaction surveys and so might be more attentive to ones from healthcare organizations. But I suspect that a reasonable portion of older patients rely on a family member to complete them, and this person, often a son or daughter, probably does get a lot of similar surveys. Surely, survey fatigue is influencing the results at least a little.

Healthcare Surveys: HCAHPS

For all the surveying going on, I find it pretty difficult to use HCAHPS results to guide patient-satisfaction improvement efforts. Sure, I can see how individual doctors or different physician groups score compared to one another and try to model my behaviors after the high performers. That is a really valuable thing to do, but it doesn’t get to the granular level I’d like.

One would hope the three physician-specific HCAHPS questions would support drilling down to more actionable information. But every hospitalist group I’ve seen always has the same pattern, scoring from lowest to highest as follows:

• How often did doctors explain things in a way you could understand?
• How often did doctors listen carefully to you?
• How often did doctors treat you with courtesy and respect?

So I don’t think the difference in scores on these questions is very useful in guiding improvement efforts.

Looking beyond HCAHPS

For a few years, our hospitalist group added a very short survey to the brochure describing the practice. I still think that was good idea to ensure accurate attribution and more granular information, but it didn’t yield much value in practice because of a low response rate. Ultimately, we stopped using it because of our hospital risk manager’s concern any such survey could be construed as “coaching” patients in their HCAHPS responses, something the Centers for Medicare & Medicaid Services forbids.

Mark Rudolph, MD, vice president of physician development and patient experience at Sound Physicians, told me about their experience with their employed RNs using tablet computers to survey every patient the day following hospital admission (i.e., while patients were still in the hospital). It seems to me this could be a really valuable tool to provide very granular feedback at the outset of a patient stay when there is still time to address areas in which the patient is less satisfied. They found that for about 30% of patients, the survey uncovered something that could be fixed, such as providing another blanket, determining what time a test was likely to be done, etc. I bet for most patients the fact that a nurse cared enough to ask how things are going and try to remedy problems improved their HCAPHS scores.

 

Yet after some experience with this approach, Sound Physicians found that, for a number of reasons, this wasn’t as valuable as hoped. They now survey a smaller sample of patients and sometimes adjust the questions based on the known or suspected strengths and weaknesses of individual providers. For one doctor, for example, the survey might ask whether the doctor spent enough time with the patient; for another, it might ask if the doctor spoke clearly, etc.

Dr. Rudolph thinks having someone such as the lead hospitalist observe the doctor while on rounds might ultimately prove more valuable than administering a survey. It will be interesting to see how his group and others around the country evolve their approach to better understand each provider’s strengths and weaknesses and most effective ways to improve patient satisfaction.

How to Improve Patient Satisfaction?

In my April 2012 column, I wrote about several things for hospitalists to consider including in their patient-satisfaction improvement plan. And, of course, there are a lot of additional sources of ideas available just by searching the Internet.

I find it difficult to consistently implement a bundle of multiple different habits, such as always sitting or always rounding with the patient’s bedside nurse, etc. I acknowledge these are proven valuable strategies to improve scores, but I still find it hard to do them consistently.

For some of us, it might be better to pick one thing to focus on. And while I don’t have research data to prove it, I think the single most valuable thing to improve patient satisfaction with hospitalists is to phone patients after discharge. It isn’t as difficult as most assume, and it often leads patients (or the family member you reach) to thank you profusely for the call. I think hospitalists can really benefit from more expressions of gratitude from patients and families, and these calls often provide it.

I’ve learned a few lessons about making post-discharge calls that are detailed in my August 2012 column. TH

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

I first became aware of measuring customer satisfaction when a service manager at a car dealership explained in an upbeat way that I would be getting a survey and that any response by me other than the highest rating would result in significant negative consequences. I can recall being pleased with the service right up to the point the manager tried to extract a promise from me that I would provide “top box” answers.

What started with a car dealership survey has become a near avalanche of surveys from my credit card, bank, airlines, hotels, and other businesses. Each starts by assuring me that it will take only a minute or two to complete the survey, but if I completed every survey sent my way, it would add up to a significant amount of time. So I’ve stopped responding to nearly all of them, not so much as a form of protest but as part of my overall time-management efforts.

I imagine many of our patients see surveys from hospitals and other healthcare providers similarly: just another one to add to the pile. Patients in their 80s and 90s—a significant portion of hospitalist patients—probably interact a lot less with companies that send satisfaction surveys and so might be more attentive to ones from healthcare organizations. But I suspect that a reasonable portion of older patients rely on a family member to complete them, and this person, often a son or daughter, probably does get a lot of similar surveys. Surely, survey fatigue is influencing the results at least a little.

Healthcare Surveys: HCAHPS

For all the surveying going on, I find it pretty difficult to use HCAHPS results to guide patient-satisfaction improvement efforts. Sure, I can see how individual doctors or different physician groups score compared to one another and try to model my behaviors after the high performers. That is a really valuable thing to do, but it doesn’t get to the granular level I’d like.

One would hope the three physician-specific HCAHPS questions would support drilling down to more actionable information. But every hospitalist group I’ve seen always has the same pattern, scoring from lowest to highest as follows:

• How often did doctors explain things in a way you could understand?
• How often did doctors listen carefully to you?
• How often did doctors treat you with courtesy and respect?

So I don’t think the difference in scores on these questions is very useful in guiding improvement efforts.

Looking beyond HCAHPS

For a few years, our hospitalist group added a very short survey to the brochure describing the practice. I still think that was good idea to ensure accurate attribution and more granular information, but it didn’t yield much value in practice because of a low response rate. Ultimately, we stopped using it because of our hospital risk manager’s concern any such survey could be construed as “coaching” patients in their HCAHPS responses, something the Centers for Medicare & Medicaid Services forbids.

Mark Rudolph, MD, vice president of physician development and patient experience at Sound Physicians, told me about their experience with their employed RNs using tablet computers to survey every patient the day following hospital admission (i.e., while patients were still in the hospital). It seems to me this could be a really valuable tool to provide very granular feedback at the outset of a patient stay when there is still time to address areas in which the patient is less satisfied. They found that for about 30% of patients, the survey uncovered something that could be fixed, such as providing another blanket, determining what time a test was likely to be done, etc. I bet for most patients the fact that a nurse cared enough to ask how things are going and try to remedy problems improved their HCAPHS scores.

 

Yet after some experience with this approach, Sound Physicians found that, for a number of reasons, this wasn’t as valuable as hoped. They now survey a smaller sample of patients and sometimes adjust the questions based on the known or suspected strengths and weaknesses of individual providers. For one doctor, for example, the survey might ask whether the doctor spent enough time with the patient; for another, it might ask if the doctor spoke clearly, etc.

Dr. Rudolph thinks having someone such as the lead hospitalist observe the doctor while on rounds might ultimately prove more valuable than administering a survey. It will be interesting to see how his group and others around the country evolve their approach to better understand each provider’s strengths and weaknesses and most effective ways to improve patient satisfaction.

How to Improve Patient Satisfaction?

In my April 2012 column, I wrote about several things for hospitalists to consider including in their patient-satisfaction improvement plan. And, of course, there are a lot of additional sources of ideas available just by searching the Internet.

I find it difficult to consistently implement a bundle of multiple different habits, such as always sitting or always rounding with the patient’s bedside nurse, etc. I acknowledge these are proven valuable strategies to improve scores, but I still find it hard to do them consistently.

For some of us, it might be better to pick one thing to focus on. And while I don’t have research data to prove it, I think the single most valuable thing to improve patient satisfaction with hospitalists is to phone patients after discharge. It isn’t as difficult as most assume, and it often leads patients (or the family member you reach) to thank you profusely for the call. I think hospitalists can really benefit from more expressions of gratitude from patients and families, and these calls often provide it.

I’ve learned a few lessons about making post-discharge calls that are detailed in my August 2012 column. TH

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

I first became aware of measuring customer satisfaction when a service manager at a car dealership explained in an upbeat way that I would be getting a survey and that any response by me other than the highest rating would result in significant negative consequences. I can recall being pleased with the service right up to the point the manager tried to extract a promise from me that I would provide “top box” answers.

What started with a car dealership survey has become a near avalanche of surveys from my credit card, bank, airlines, hotels, and other businesses. Each starts by assuring me that it will take only a minute or two to complete the survey, but if I completed every survey sent my way, it would add up to a significant amount of time. So I’ve stopped responding to nearly all of them, not so much as a form of protest but as part of my overall time-management efforts.

I imagine many of our patients see surveys from hospitals and other healthcare providers similarly: just another one to add to the pile. Patients in their 80s and 90s—a significant portion of hospitalist patients—probably interact a lot less with companies that send satisfaction surveys and so might be more attentive to ones from healthcare organizations. But I suspect that a reasonable portion of older patients rely on a family member to complete them, and this person, often a son or daughter, probably does get a lot of similar surveys. Surely, survey fatigue is influencing the results at least a little.

Healthcare Surveys: HCAHPS

For all the surveying going on, I find it pretty difficult to use HCAHPS results to guide patient-satisfaction improvement efforts. Sure, I can see how individual doctors or different physician groups score compared to one another and try to model my behaviors after the high performers. That is a really valuable thing to do, but it doesn’t get to the granular level I’d like.

One would hope the three physician-specific HCAHPS questions would support drilling down to more actionable information. But every hospitalist group I’ve seen always has the same pattern, scoring from lowest to highest as follows:

• How often did doctors explain things in a way you could understand?
• How often did doctors listen carefully to you?
• How often did doctors treat you with courtesy and respect?

So I don’t think the difference in scores on these questions is very useful in guiding improvement efforts.

Looking beyond HCAHPS

For a few years, our hospitalist group added a very short survey to the brochure describing the practice. I still think that was good idea to ensure accurate attribution and more granular information, but it didn’t yield much value in practice because of a low response rate. Ultimately, we stopped using it because of our hospital risk manager’s concern any such survey could be construed as “coaching” patients in their HCAHPS responses, something the Centers for Medicare & Medicaid Services forbids.

Mark Rudolph, MD, vice president of physician development and patient experience at Sound Physicians, told me about their experience with their employed RNs using tablet computers to survey every patient the day following hospital admission (i.e., while patients were still in the hospital). It seems to me this could be a really valuable tool to provide very granular feedback at the outset of a patient stay when there is still time to address areas in which the patient is less satisfied. They found that for about 30% of patients, the survey uncovered something that could be fixed, such as providing another blanket, determining what time a test was likely to be done, etc. I bet for most patients the fact that a nurse cared enough to ask how things are going and try to remedy problems improved their HCAPHS scores.

 

Yet after some experience with this approach, Sound Physicians found that, for a number of reasons, this wasn’t as valuable as hoped. They now survey a smaller sample of patients and sometimes adjust the questions based on the known or suspected strengths and weaknesses of individual providers. For one doctor, for example, the survey might ask whether the doctor spent enough time with the patient; for another, it might ask if the doctor spoke clearly, etc.

Dr. Rudolph thinks having someone such as the lead hospitalist observe the doctor while on rounds might ultimately prove more valuable than administering a survey. It will be interesting to see how his group and others around the country evolve their approach to better understand each provider’s strengths and weaknesses and most effective ways to improve patient satisfaction.

How to Improve Patient Satisfaction?

In my April 2012 column, I wrote about several things for hospitalists to consider including in their patient-satisfaction improvement plan. And, of course, there are a lot of additional sources of ideas available just by searching the Internet.

I find it difficult to consistently implement a bundle of multiple different habits, such as always sitting or always rounding with the patient’s bedside nurse, etc. I acknowledge these are proven valuable strategies to improve scores, but I still find it hard to do them consistently.

For some of us, it might be better to pick one thing to focus on. And while I don’t have research data to prove it, I think the single most valuable thing to improve patient satisfaction with hospitalists is to phone patients after discharge. It isn’t as difficult as most assume, and it often leads patients (or the family member you reach) to thank you profusely for the call. I think hospitalists can really benefit from more expressions of gratitude from patients and families, and these calls often provide it.

I’ve learned a few lessons about making post-discharge calls that are detailed in my August 2012 column. TH

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

 

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

 

 

 

Question: What inspired you to begin working in hospital medicine and later join SHM?

 

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

 

Q: How has SHM provided you with resources to improve patient care during your time as a member?

 

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

 

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

 

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

 

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

 

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

 

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

 

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

 

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

 

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

 

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

 

 

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

 

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

 

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

 

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

 

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

 

 

 

Question: What inspired you to begin working in hospital medicine and later join SHM?

 

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

 

Q: How has SHM provided you with resources to improve patient care during your time as a member?

 

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

 

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

 

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

 

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

 

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

 

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

 

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

 

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

 

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

 

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

 

 

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

 

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

 

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

 

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

 

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

 

 

 

Question: What inspired you to begin working in hospital medicine and later join SHM?

 

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

 

Q: How has SHM provided you with resources to improve patient care during your time as a member?

 

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

 

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

 

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

 

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

 

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

 

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

 

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

 

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

 

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

 

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

 

 

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

 

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

 

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

 

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Does naloxone co-prescription for patients on long-term opioids for pain prevent opioid-related adverse events?

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Does naloxone co-prescription for patients on long-term opioids for pain prevent opioid-related adverse events?

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Does naloxone co-prescription for patients on long-term opioids for pain prevent opioid-related adverse events?

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Pain is a completely subjective experience that is the consequence of the filtering, modulating, and distorting of the afferent nerve activity through the affective and cognitive processes unique to each individual. This module discusses why postoperative pain requires treatment, outlines methods for performing an assessment of pain, provides strategies for using patient-controlled analgesia, and summarizes the use of opioid and non-opioid analgesics in the postoperative setting.

 

Start earning free CME credits today at www.shmconsults.com.

Pain is a completely subjective experience that is the consequence of the filtering, modulating, and distorting of the afferent nerve activity through the affective and cognitive processes unique to each individual. This module discusses why postoperative pain requires treatment, outlines methods for performing an assessment of pain, provides strategies for using patient-controlled analgesia, and summarizes the use of opioid and non-opioid analgesics in the postoperative setting.

 

Start earning free CME credits today at www.shmconsults.com.

Pain is a completely subjective experience that is the consequence of the filtering, modulating, and distorting of the afferent nerve activity through the affective and cognitive processes unique to each individual. This module discusses why postoperative pain requires treatment, outlines methods for performing an assessment of pain, provides strategies for using patient-controlled analgesia, and summarizes the use of opioid and non-opioid analgesics in the postoperative setting.

 

Start earning free CME credits today at www.shmconsults.com.

Increase your confidence about your knowledge and skills with shmConsults, consultative and perioperative medicine essentials for hospitalists. shmConsults modules are free to both SHM members and non-members and offer up to 2.0 AMA PRA Category 1 Credit per module. New modules include:

Appropriate Use of Targeted Oral Anticoagulants to Prevent Stroke in Patients with Nonvalvular Atrial Fibrillation

This activity includes thorough discussions on initial management of patients with nonvalvular atrial fibrillation (NVAF), appropriate situations for oral anticoagulation in the presence of NVAF, appropriate choice of oral anticoagulant, reversal of oral anticoagulation, and guidelines for oral anticoagulation and stroke prevention in NVAF patients and special-population NVAF patients.

Four modules addressing various aspects of anticoagulation/thrombosis have been updated and include:

• Target-Specific Oral Anticoagulants for Stroke Prophylaxis in Patients with NVAF
• Management of Postoperative Atrial Fibrillation
• Perioperative Bridging of Anticoagulant Therapy
• Perioperative Management of Anticoagulation

Increase your confidence about your knowledge and skills with shmConsults, consultative and perioperative medicine essentials for hospitalists. shmConsults modules are free to both SHM members and non-members and offer up to 2.0 AMA PRA Category 1 Credit per module. New modules include:

Appropriate Use of Targeted Oral Anticoagulants to Prevent Stroke in Patients with Nonvalvular Atrial Fibrillation

This activity includes thorough discussions on initial management of patients with nonvalvular atrial fibrillation (NVAF), appropriate situations for oral anticoagulation in the presence of NVAF, appropriate choice of oral anticoagulant, reversal of oral anticoagulation, and guidelines for oral anticoagulation and stroke prevention in NVAF patients and special-population NVAF patients.

Four modules addressing various aspects of anticoagulation/thrombosis have been updated and include:

• Target-Specific Oral Anticoagulants for Stroke Prophylaxis in Patients with NVAF
• Management of Postoperative Atrial Fibrillation
• Perioperative Bridging of Anticoagulant Therapy
• Perioperative Management of Anticoagulation

Increase your confidence about your knowledge and skills with shmConsults, consultative and perioperative medicine essentials for hospitalists. shmConsults modules are free to both SHM members and non-members and offer up to 2.0 AMA PRA Category 1 Credit per module. New modules include:

Appropriate Use of Targeted Oral Anticoagulants to Prevent Stroke in Patients with Nonvalvular Atrial Fibrillation

This activity includes thorough discussions on initial management of patients with nonvalvular atrial fibrillation (NVAF), appropriate situations for oral anticoagulation in the presence of NVAF, appropriate choice of oral anticoagulant, reversal of oral anticoagulation, and guidelines for oral anticoagulation and stroke prevention in NVAF patients and special-population NVAF patients.

Four modules addressing various aspects of anticoagulation/thrombosis have been updated and include:

• Target-Specific Oral Anticoagulants for Stroke Prophylaxis in Patients with NVAF
• Management of Postoperative Atrial Fibrillation
• Perioperative Bridging of Anticoagulant Therapy
• Perioperative Management of Anticoagulation

The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.

We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.

We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.

Below are our reasons for opposing this formal certification.

We already have a fellowship system.

As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.

Subspecialization has opportunity costs that may reduce the PHM pipeline.

Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5

 

More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7

Certification will pose a potential risk to specific patient populations.

We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.

Pediatric residency trains pediatricians in inpatient care.

We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.

Primary care should require subspecialty certification as well.

Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.

The target should be residency training.

The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.

 

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

1. Chen C, Eagle S. “Should Pediatric HM Pursue Subspecialty Certification, Required Fellowship Training?” The Hospitalist. July 31, 2012
2. Results and Data: Specialties Matching Service 2016 Appointment Year. National Resident Matching Program website. Accessed May 15, 2016.
3. Medscape Pediatrician Compensation Report 2015. Medscape website.  Accessed April 29, 2016.
4. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2001;127(2):254-260.
5. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973-1975.
6. O’Toole JK, Friedland AR, Gonzaga AM, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr. 2015;5(6):309-314.
7. Society of Hospital Medicine: Survey of Med-Peds Physicians about PHM Certification. May 2014 (unpublished).
8. Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: inpatient experience in children’s hospitals. Pediatrics. 2011;128(1):5-13.
9. Freed GL, Dunham KM, Research Advisory Committee of the American Board of P. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179-186.
10. Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The med-peds hospitalist workforce: results from the American Academy of Pediatrics Workforce Survey. Hosp Pediatr. 2015;5(11):574-579.

The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.

We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.

We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.

Below are our reasons for opposing this formal certification.

We already have a fellowship system.

As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.

Subspecialization has opportunity costs that may reduce the PHM pipeline.

Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5

 

More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7

Certification will pose a potential risk to specific patient populations.

We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.

Pediatric residency trains pediatricians in inpatient care.

We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.

Primary care should require subspecialty certification as well.

Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.

The target should be residency training.

The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.

 

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

1. Chen C, Eagle S. “Should Pediatric HM Pursue Subspecialty Certification, Required Fellowship Training?” The Hospitalist. July 31, 2012
2. Results and Data: Specialties Matching Service 2016 Appointment Year. National Resident Matching Program website. Accessed May 15, 2016.
3. Medscape Pediatrician Compensation Report 2015. Medscape website.  Accessed April 29, 2016.
4. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2001;127(2):254-260.
5. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973-1975.
6. O’Toole JK, Friedland AR, Gonzaga AM, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr. 2015;5(6):309-314.
7. Society of Hospital Medicine: Survey of Med-Peds Physicians about PHM Certification. May 2014 (unpublished).
8. Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: inpatient experience in children’s hospitals. Pediatrics. 2011;128(1):5-13.
9. Freed GL, Dunham KM, Research Advisory Committee of the American Board of P. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179-186.
10. Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The med-peds hospitalist workforce: results from the American Academy of Pediatrics Workforce Survey. Hosp Pediatr. 2015;5(11):574-579.

The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.

We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.

We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.

Below are our reasons for opposing this formal certification.

We already have a fellowship system.

As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.

Subspecialization has opportunity costs that may reduce the PHM pipeline.

Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5

 

More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7

Certification will pose a potential risk to specific patient populations.

We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.

Pediatric residency trains pediatricians in inpatient care.

We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.

Primary care should require subspecialty certification as well.

Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.

The target should be residency training.

The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.

 

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

1. Chen C, Eagle S. “Should Pediatric HM Pursue Subspecialty Certification, Required Fellowship Training?” The Hospitalist. July 31, 2012
2. Results and Data: Specialties Matching Service 2016 Appointment Year. National Resident Matching Program website. Accessed May 15, 2016.
3. Medscape Pediatrician Compensation Report 2015. Medscape website.  Accessed April 29, 2016.
4. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2001;127(2):254-260.
5. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973-1975.
6. O’Toole JK, Friedland AR, Gonzaga AM, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr. 2015;5(6):309-314.
7. Society of Hospital Medicine: Survey of Med-Peds Physicians about PHM Certification. May 2014 (unpublished).
8. Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: inpatient experience in children’s hospitals. Pediatrics. 2011;128(1):5-13.
9. Freed GL, Dunham KM, Research Advisory Committee of the American Board of P. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179-186.
10. Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The med-peds hospitalist workforce: results from the American Academy of Pediatrics Workforce Survey. Hosp Pediatr. 2015;5(11):574-579.

Clinical Question: Is there a difference in family-rated quality of care for patients dying with different serious illnesses?

Background: End-of-life care has focused largely on cancer patients. However, other conditions lead to more deaths than cancer in the United States.

Study Design: A retrospective cross-sectional study.

Setting: 146 inpatient Veterans Affairs (VA) facilities.

Synopsis: This study included 57,753 patients who died in inpatient facilities with a diagnosis of cancer, dementia, end-stage renal disease (ESRD), cardiopulmonary failure (heart failure or chronic obstructive pulmonary disease), or frailty. Measures included palliative care consultations, do-not-resuscitate (DNR) orders, death in inpatient hospice, death in the intensive care unit (ICU), and family-reported quality of end-of-life care. Palliative care consultations were given to 73.5% of patients with cancer and 61.4% of patients with dementia, which was significantly more than patients with other diagnoses (P < .001).

Approximately one-third of patients with diagnoses other than cancer or dementia died in the ICU, which was more than double the rate among patients with cancer or dementia (P < .001). Rates of excellent quality of end-of-life care were similar for patients with cancer and dementia (59.2% and 59.3%) but lower for other conditions (P = 0.02 when compared with cancer patient). This was mediated by palliative care consultation, setting of death, and DNR status. Difficulty defining frailty and restriction to only the VA system are limitations of this study.

Bottom Line: Increasing access to palliative care, goals-of-care discussions, and preferred setting of death may improve overall quality of end-of-life care.

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. doi:10.1001/jamainternmed.2016.1200.

Clinical Question: Is there a difference in family-rated quality of care for patients dying with different serious illnesses?

Background: End-of-life care has focused largely on cancer patients. However, other conditions lead to more deaths than cancer in the United States.

Study Design: A retrospective cross-sectional study.

Setting: 146 inpatient Veterans Affairs (VA) facilities.

Synopsis: This study included 57,753 patients who died in inpatient facilities with a diagnosis of cancer, dementia, end-stage renal disease (ESRD), cardiopulmonary failure (heart failure or chronic obstructive pulmonary disease), or frailty. Measures included palliative care consultations, do-not-resuscitate (DNR) orders, death in inpatient hospice, death in the intensive care unit (ICU), and family-reported quality of end-of-life care. Palliative care consultations were given to 73.5% of patients with cancer and 61.4% of patients with dementia, which was significantly more than patients with other diagnoses (P < .001).

Approximately one-third of patients with diagnoses other than cancer or dementia died in the ICU, which was more than double the rate among patients with cancer or dementia (P < .001). Rates of excellent quality of end-of-life care were similar for patients with cancer and dementia (59.2% and 59.3%) but lower for other conditions (P = 0.02 when compared with cancer patient). This was mediated by palliative care consultation, setting of death, and DNR status. Difficulty defining frailty and restriction to only the VA system are limitations of this study.

Bottom Line: Increasing access to palliative care, goals-of-care discussions, and preferred setting of death may improve overall quality of end-of-life care.

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. doi:10.1001/jamainternmed.2016.1200.

Clinical Question: Is there a difference in family-rated quality of care for patients dying with different serious illnesses?

Background: End-of-life care has focused largely on cancer patients. However, other conditions lead to more deaths than cancer in the United States.

Study Design: A retrospective cross-sectional study.

Setting: 146 inpatient Veterans Affairs (VA) facilities.

Synopsis: This study included 57,753 patients who died in inpatient facilities with a diagnosis of cancer, dementia, end-stage renal disease (ESRD), cardiopulmonary failure (heart failure or chronic obstructive pulmonary disease), or frailty. Measures included palliative care consultations, do-not-resuscitate (DNR) orders, death in inpatient hospice, death in the intensive care unit (ICU), and family-reported quality of end-of-life care. Palliative care consultations were given to 73.5% of patients with cancer and 61.4% of patients with dementia, which was significantly more than patients with other diagnoses (P < .001).

Approximately one-third of patients with diagnoses other than cancer or dementia died in the ICU, which was more than double the rate among patients with cancer or dementia (P < .001). Rates of excellent quality of end-of-life care were similar for patients with cancer and dementia (59.2% and 59.3%) but lower for other conditions (P = 0.02 when compared with cancer patient). This was mediated by palliative care consultation, setting of death, and DNR status. Difficulty defining frailty and restriction to only the VA system are limitations of this study.

Bottom Line: Increasing access to palliative care, goals-of-care discussions, and preferred setting of death may improve overall quality of end-of-life care.

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. doi:10.1001/jamainternmed.2016.1200.