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Warfarin Reduces Risk of Ischemic Stroke in High-Risk Patients
Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.
Study design: Retrospective cohort study.
Setting: National Health Research Institutes, Taiwan.
Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.
Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.
Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.
Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.
Study design: Retrospective cohort study.
Setting: National Health Research Institutes, Taiwan.
Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.
Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.
Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.
Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.
Study design: Retrospective cohort study.
Setting: National Health Research Institutes, Taiwan.
Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.
Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.
Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.
Medical Student Guides Aspiring Physicians into Hospital Medicine
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. You can get involved, too! 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 Aram Namavar, MS, a recipient of SHM’s Student Hospitalist Scholar Grant and a second-year medical student at Loyola University Chicago’s Stritch School of Medicine. Namavar is one of the first students to sit on an SHM committee as part of the Physicians in Training (PIT) Committee, which is focused on ensuring the successful transition of medical students and residents into the practice of hospital medicine. He recently started a hospital medicine special interest group at his medical school and is playing an active role in the launch of SHM’s new Students Community on the Hospital Medicine Exchange (HMX).
What piqued your interest in hospital medicine as you were choosing a specialty?
The laundry room was located right next to the training room, so I had the opportunity to meet the orthopedic surgeons and training staff. After spending some time in this program, I felt that there were aspects to a career in orthopedics that did not fit with my personality, such as what I felt was limited patient interaction and ability to impact multiple domains of their care outside of surgery. I pivoted and began volunteering at UCLA Health and was exposed to a plethora of medical specialties and patient populations. Through the self-discovery of my potential career path, I also discovered myself and my values. I realized that I desired flexibility and versatility in my career to engage in clinical, leadership, mentorship, research, education, and advocacy roles, all of which are possible in hospital medicine. I am now certain that my career in medicine will lead me to become an academic hospitalist.
Can you tell us about your quality improvement project that you initiated as a result of winning the SHM Student Hospitalist Scholar Grant?
This summer has been a very enriching experience for my personal and professional development. My main project is focused on patient-centered readmissions and has three components. I am promoting a patient-centered approach to readmissions through examination of the role that decisional conflict plays in hospital readmissions.
In shared decision-making models, decisional conflict is a measure of uncertainty, readiness, and comfort level in making a decision. Aware of the plight of diverse populations in accessing healthcare and having higher readmission rates, I have widened the scope of my project. A second arm of my study is investigating which social determinants of health may be a root cause for why Hispanic patients are being readmitted at an increased rate compared to their non-readmitted counterparts. The third arm of my study is elucidating patient-centered views of the cause and preventability of readmission for Hispanic versus non-Hispanic patients.
What inspired you to become involved with the PIT Committee?
Working with undergraduate and medical students and resident physicians, I have always had a passion for inspiring the future of medicine. Even in hospital medicine’s 20 years of existence, I knew there were many opportunities for me to engage trainees. For this reason, I applied for a seat on the PIT Committee and was accepted as the only medical student to sit on an SHM committee.
Having founded the first hospital medicine interest group at a medical school in the U.S. at Loyola, my work on the PIT Committee is focused on enhancing our ability to engage medical students and residents. I am a member of the Student Interest Group Task Force that is creating a toolkit for medical schools from across the nation to gain recognition from SHM for creating a hospital medicine interest group. The blueprint we used at Loyola is being adopted and incorporated in our toolkit. Another avenue of engagement is through the new Students Community on HMX, SHM’s online member engagement platform. This new community, which I helped to launch, will serve as an important channel for us to connect with trainees nationally and encourage them to consider hospital medicine as a specialty.
What opportunities do you see for hospitalists as the medical landscape continues to evolve?
I see hospitalists playing important roles in value-based care and population health. Hospitalists have carved their niche in quality improvement within health systems, and I believe they will be best suited for spearheading projects to enhance the value of medical care. Hospitalists will also no longer have an impact within the confines of a hospital as the landscape is shifting toward population health; therefore, hospitalists will be charged with helping to devise methods to proactively identify care gaps in their patients to promote preventive care and chronic disease management.
What would you tell medical students about choosing hospital medicine as a career?
I believe that a career in hospital medicine is one of the most versatile. If you are someone who must be continually stimulated by various work settings, then hospital medicine is right for you. I enjoy multidimensional work, and as a future academic hospitalist, I know that my scope of practice will include mentorship, education, research, leadership, and clinical duties. The ability to have such a versatile career will be extremely fulfilling.
What’s next for you in your medical career?
As a second-year medical student, my primary focus is on succeeding academically and adequately preparing for my USMLE Step 1 exam to match at my desired internal medicine residency program. Outside of my studies, I am continuing to develop my analytical skills and leadership acumen so that I can become a major player in hospital medicine once I am an academic hospitalist. After residency, I will be pursuing a fully employed MBA program where I will be equipped with the necessary skills to realize my professional goals. 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. You can get involved, too! 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 Aram Namavar, MS, a recipient of SHM’s Student Hospitalist Scholar Grant and a second-year medical student at Loyola University Chicago’s Stritch School of Medicine. Namavar is one of the first students to sit on an SHM committee as part of the Physicians in Training (PIT) Committee, which is focused on ensuring the successful transition of medical students and residents into the practice of hospital medicine. He recently started a hospital medicine special interest group at his medical school and is playing an active role in the launch of SHM’s new Students Community on the Hospital Medicine Exchange (HMX).
What piqued your interest in hospital medicine as you were choosing a specialty?
The laundry room was located right next to the training room, so I had the opportunity to meet the orthopedic surgeons and training staff. After spending some time in this program, I felt that there were aspects to a career in orthopedics that did not fit with my personality, such as what I felt was limited patient interaction and ability to impact multiple domains of their care outside of surgery. I pivoted and began volunteering at UCLA Health and was exposed to a plethora of medical specialties and patient populations. Through the self-discovery of my potential career path, I also discovered myself and my values. I realized that I desired flexibility and versatility in my career to engage in clinical, leadership, mentorship, research, education, and advocacy roles, all of which are possible in hospital medicine. I am now certain that my career in medicine will lead me to become an academic hospitalist.
Can you tell us about your quality improvement project that you initiated as a result of winning the SHM Student Hospitalist Scholar Grant?
This summer has been a very enriching experience for my personal and professional development. My main project is focused on patient-centered readmissions and has three components. I am promoting a patient-centered approach to readmissions through examination of the role that decisional conflict plays in hospital readmissions.
In shared decision-making models, decisional conflict is a measure of uncertainty, readiness, and comfort level in making a decision. Aware of the plight of diverse populations in accessing healthcare and having higher readmission rates, I have widened the scope of my project. A second arm of my study is investigating which social determinants of health may be a root cause for why Hispanic patients are being readmitted at an increased rate compared to their non-readmitted counterparts. The third arm of my study is elucidating patient-centered views of the cause and preventability of readmission for Hispanic versus non-Hispanic patients.
What inspired you to become involved with the PIT Committee?
Working with undergraduate and medical students and resident physicians, I have always had a passion for inspiring the future of medicine. Even in hospital medicine’s 20 years of existence, I knew there were many opportunities for me to engage trainees. For this reason, I applied for a seat on the PIT Committee and was accepted as the only medical student to sit on an SHM committee.
Having founded the first hospital medicine interest group at a medical school in the U.S. at Loyola, my work on the PIT Committee is focused on enhancing our ability to engage medical students and residents. I am a member of the Student Interest Group Task Force that is creating a toolkit for medical schools from across the nation to gain recognition from SHM for creating a hospital medicine interest group. The blueprint we used at Loyola is being adopted and incorporated in our toolkit. Another avenue of engagement is through the new Students Community on HMX, SHM’s online member engagement platform. This new community, which I helped to launch, will serve as an important channel for us to connect with trainees nationally and encourage them to consider hospital medicine as a specialty.
What opportunities do you see for hospitalists as the medical landscape continues to evolve?
I see hospitalists playing important roles in value-based care and population health. Hospitalists have carved their niche in quality improvement within health systems, and I believe they will be best suited for spearheading projects to enhance the value of medical care. Hospitalists will also no longer have an impact within the confines of a hospital as the landscape is shifting toward population health; therefore, hospitalists will be charged with helping to devise methods to proactively identify care gaps in their patients to promote preventive care and chronic disease management.
What would you tell medical students about choosing hospital medicine as a career?
I believe that a career in hospital medicine is one of the most versatile. If you are someone who must be continually stimulated by various work settings, then hospital medicine is right for you. I enjoy multidimensional work, and as a future academic hospitalist, I know that my scope of practice will include mentorship, education, research, leadership, and clinical duties. The ability to have such a versatile career will be extremely fulfilling.
What’s next for you in your medical career?
As a second-year medical student, my primary focus is on succeeding academically and adequately preparing for my USMLE Step 1 exam to match at my desired internal medicine residency program. Outside of my studies, I am continuing to develop my analytical skills and leadership acumen so that I can become a major player in hospital medicine once I am an academic hospitalist. After residency, I will be pursuing a fully employed MBA program where I will be equipped with the necessary skills to realize my professional goals. 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. You can get involved, too! 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 Aram Namavar, MS, a recipient of SHM’s Student Hospitalist Scholar Grant and a second-year medical student at Loyola University Chicago’s Stritch School of Medicine. Namavar is one of the first students to sit on an SHM committee as part of the Physicians in Training (PIT) Committee, which is focused on ensuring the successful transition of medical students and residents into the practice of hospital medicine. He recently started a hospital medicine special interest group at his medical school and is playing an active role in the launch of SHM’s new Students Community on the Hospital Medicine Exchange (HMX).
What piqued your interest in hospital medicine as you were choosing a specialty?
The laundry room was located right next to the training room, so I had the opportunity to meet the orthopedic surgeons and training staff. After spending some time in this program, I felt that there were aspects to a career in orthopedics that did not fit with my personality, such as what I felt was limited patient interaction and ability to impact multiple domains of their care outside of surgery. I pivoted and began volunteering at UCLA Health and was exposed to a plethora of medical specialties and patient populations. Through the self-discovery of my potential career path, I also discovered myself and my values. I realized that I desired flexibility and versatility in my career to engage in clinical, leadership, mentorship, research, education, and advocacy roles, all of which are possible in hospital medicine. I am now certain that my career in medicine will lead me to become an academic hospitalist.
Can you tell us about your quality improvement project that you initiated as a result of winning the SHM Student Hospitalist Scholar Grant?
This summer has been a very enriching experience for my personal and professional development. My main project is focused on patient-centered readmissions and has three components. I am promoting a patient-centered approach to readmissions through examination of the role that decisional conflict plays in hospital readmissions.
In shared decision-making models, decisional conflict is a measure of uncertainty, readiness, and comfort level in making a decision. Aware of the plight of diverse populations in accessing healthcare and having higher readmission rates, I have widened the scope of my project. A second arm of my study is investigating which social determinants of health may be a root cause for why Hispanic patients are being readmitted at an increased rate compared to their non-readmitted counterparts. The third arm of my study is elucidating patient-centered views of the cause and preventability of readmission for Hispanic versus non-Hispanic patients.
What inspired you to become involved with the PIT Committee?
Working with undergraduate and medical students and resident physicians, I have always had a passion for inspiring the future of medicine. Even in hospital medicine’s 20 years of existence, I knew there were many opportunities for me to engage trainees. For this reason, I applied for a seat on the PIT Committee and was accepted as the only medical student to sit on an SHM committee.
Having founded the first hospital medicine interest group at a medical school in the U.S. at Loyola, my work on the PIT Committee is focused on enhancing our ability to engage medical students and residents. I am a member of the Student Interest Group Task Force that is creating a toolkit for medical schools from across the nation to gain recognition from SHM for creating a hospital medicine interest group. The blueprint we used at Loyola is being adopted and incorporated in our toolkit. Another avenue of engagement is through the new Students Community on HMX, SHM’s online member engagement platform. This new community, which I helped to launch, will serve as an important channel for us to connect with trainees nationally and encourage them to consider hospital medicine as a specialty.
What opportunities do you see for hospitalists as the medical landscape continues to evolve?
I see hospitalists playing important roles in value-based care and population health. Hospitalists have carved their niche in quality improvement within health systems, and I believe they will be best suited for spearheading projects to enhance the value of medical care. Hospitalists will also no longer have an impact within the confines of a hospital as the landscape is shifting toward population health; therefore, hospitalists will be charged with helping to devise methods to proactively identify care gaps in their patients to promote preventive care and chronic disease management.
What would you tell medical students about choosing hospital medicine as a career?
I believe that a career in hospital medicine is one of the most versatile. If you are someone who must be continually stimulated by various work settings, then hospital medicine is right for you. I enjoy multidimensional work, and as a future academic hospitalist, I know that my scope of practice will include mentorship, education, research, leadership, and clinical duties. The ability to have such a versatile career will be extremely fulfilling.
What’s next for you in your medical career?
As a second-year medical student, my primary focus is on succeeding academically and adequately preparing for my USMLE Step 1 exam to match at my desired internal medicine residency program. Outside of my studies, I am continuing to develop my analytical skills and leadership acumen so that I can become a major player in hospital medicine once I am an academic hospitalist. After residency, I will be pursuing a fully employed MBA program where I will be equipped with the necessary skills to realize my professional goals. TH
Thinking through the State of Hospital Medicine Report
sSHM’s 2016 State of Hospital Medicine Report (SoHM) is now available, and it’s unquestionably the best source of detail regarding how hospital medicine groups are configured and operated.1
The SoHM is published in even years and combines data from two sources:
- Hospitalist data from Medical Group Management Association’s Physician Compensation and Productivity Survey. Within the SoHM, you will find the same figures for hospitalist compensation, production, and a few related metrics that are from the MGMA survey report.
- SHM’s survey of hospital medicine groups. This survey drills into significant detail on things like scope of clinical practice, staffing levels, work schedules, bonus metrics, CPT code distribution, roles for NPs and PAs, and the amount of financial support provided to the group.
There are several new topics in this year’s SoHM, including CME allowances, utilization of prolonged service codes, and charge capture methodologies being used by hospital medicine groups. My colleague, Leslie Flores, has been very involved in the survey for 10 years and has written a blog with more details.
One Caveat …
The mix of survey respondents varies and includes a much larger portion of hospital medicine groups employed by multi-state management companies than prior surveys. Even if a parameter hasn’t changed for any hospitalist group, the fact that responses come from different contingents of the hospitalist workforce can result in a different result from one survey to the next. It is difficult to be certain if variations across successive surveys reflect a real change in the marketplace or are a function of variation in the respondent population.
Now let’s review and analyze some of this year’s survey findings for hospital medicine groups caring for adults:
Financial Support Stayed Flat
The amount of financial support provided to a hospital medicine group per FTE has increased significantly in every prior survey. This money typically comes from the hospital that the hospital medicine group serves and is sometimes referred to as the “subsidy.” For hospital medicine groups serving adults, it was $139,000 in 2012 and $156,000 in 2014.
The current survey showed a median of $157,500, essentially unchanged from two years prior. This is either an aberration in the survey (e.g., a result of a different survey population) or an indicator that this amount has begun to level off. Clearly, there is an upper limit to the amount of financial support the marketplace can support, but from my experience working with hospitalist groups around the country, I haven’t seen evidence that we’ve reached that point. I suspect it is an aberration and future surveys will show a continued rising trend, though perhaps not as rapidly as in years past.
Compensation Method Is Evolving
A mean of 14.7% of compensation was tied to production, up from around 10% in prior surveys. And the portion tied to performance (e.g., patient satisfaction, quality metrics) was unchanged at 6%. It’s interesting that despite proliferation of pay-for-performance programs and increasing emphasis on quality and value, it is the productivity portion of compensation that increased. It’s hard to know if that is a meaningful trend.
Compensation Amount Continues to Increase
For hospitalists caring for adults, the median amount of compensation rose to $278,746, up from $253,000 in 2014, $234,000 in 2013, and $221,000 in 2011. These figures come from the MGMA survey, and the financial support figures above come from the separate SHM survey. That means it’s impossible to make firm conclusions about how the numbers do or don’t interrelate.
Don’t forget that surveys report all forms of compensation, including base, production, bonus, extra shifts, and other elements. This year’s $278,746 includes all the bonus dollars earned by each hospitalist in the survey. We can make a very rough guess at the bonus by multiplying the portion of total compensation tied to performance in the SHM survey (6%) by the total compensation ($278,746) from the MGMA survey, which comes to $13,397. But we still don’t know the portion of the total bonus dollars available that represents. My experience is that the total bonus dollars available is around $20,000 or more at most hospital medicine groups. Therefore, a doctor who earned $13,397 presumably didn’t meet all performance goals.
A Deeper Dive into Hospital Medicine Group Finances
It is really interesting to ponder where the dollars come from to fund higher hospitalist compensation if the financial support provided per FTE hasn’t increased. Perhaps hospitalists are generating more encounters, work relative value units (wRVUs), or professional fee collections?
Median professional fee collections were $213,000 this year, up from $151,000 in the prior survey two years ago. This increase could, in theory, fully fund the higher hospitalist compensation without the need for an increase in other sources of revenue.
So why are collections up? It could be because hospitalists are coding the average visit at a higher level: 2.02 wRVUs per encounter this year compared to 1.97 in 2014 and 1.91 in 2012. The survey can’t help distinguish whether this increase is because we’re seeing more complex patients or whether we’re improving our documentation to catch up with the complexity of the patients we’ve been seeing all along. I suspect it is both.
The increase in wRVUs per encounter, however, is offset by a continued downward trend in numbers of encounters: 1,684 this year compared to 1,850 in 2014 and 2,078 in 2012. The total wRVUs generated per hospitalist in a year stayed about the same at 4,247 compared to 4,298 in 2014.
The best explanation for why total collections are up would be that payor rates have increased. But Medicare, which accounts for about 60%–65% of the payor mix for most hospital medicine groups, hasn’t increased rates enough to explain this, and I’m not aware of other payor classes that have increased significantly. Another explanation could be that hospital medicine groups are simply doing a better job with billing and collections and other revenue-cycle management activities, resulting in increased revenue.
I guess it shouldn’t be surprising that some of the survey results don’t seem internally consistent. The data come from two different surveys, the response rate for each question varies, and other issues mean the survey just can’t provide that level of precision. We also need to keep in mind that analyses like I’ve provided here are only very rough explanations. But I think they’re still valuable to think about even if they don’t provide definitive answers. TH
Reference
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed August 9, 2016.
sSHM’s 2016 State of Hospital Medicine Report (SoHM) is now available, and it’s unquestionably the best source of detail regarding how hospital medicine groups are configured and operated.1
The SoHM is published in even years and combines data from two sources:
- Hospitalist data from Medical Group Management Association’s Physician Compensation and Productivity Survey. Within the SoHM, you will find the same figures for hospitalist compensation, production, and a few related metrics that are from the MGMA survey report.
- SHM’s survey of hospital medicine groups. This survey drills into significant detail on things like scope of clinical practice, staffing levels, work schedules, bonus metrics, CPT code distribution, roles for NPs and PAs, and the amount of financial support provided to the group.
There are several new topics in this year’s SoHM, including CME allowances, utilization of prolonged service codes, and charge capture methodologies being used by hospital medicine groups. My colleague, Leslie Flores, has been very involved in the survey for 10 years and has written a blog with more details.
One Caveat …
The mix of survey respondents varies and includes a much larger portion of hospital medicine groups employed by multi-state management companies than prior surveys. Even if a parameter hasn’t changed for any hospitalist group, the fact that responses come from different contingents of the hospitalist workforce can result in a different result from one survey to the next. It is difficult to be certain if variations across successive surveys reflect a real change in the marketplace or are a function of variation in the respondent population.
Now let’s review and analyze some of this year’s survey findings for hospital medicine groups caring for adults:
Financial Support Stayed Flat
The amount of financial support provided to a hospital medicine group per FTE has increased significantly in every prior survey. This money typically comes from the hospital that the hospital medicine group serves and is sometimes referred to as the “subsidy.” For hospital medicine groups serving adults, it was $139,000 in 2012 and $156,000 in 2014.
The current survey showed a median of $157,500, essentially unchanged from two years prior. This is either an aberration in the survey (e.g., a result of a different survey population) or an indicator that this amount has begun to level off. Clearly, there is an upper limit to the amount of financial support the marketplace can support, but from my experience working with hospitalist groups around the country, I haven’t seen evidence that we’ve reached that point. I suspect it is an aberration and future surveys will show a continued rising trend, though perhaps not as rapidly as in years past.
Compensation Method Is Evolving
A mean of 14.7% of compensation was tied to production, up from around 10% in prior surveys. And the portion tied to performance (e.g., patient satisfaction, quality metrics) was unchanged at 6%. It’s interesting that despite proliferation of pay-for-performance programs and increasing emphasis on quality and value, it is the productivity portion of compensation that increased. It’s hard to know if that is a meaningful trend.
Compensation Amount Continues to Increase
For hospitalists caring for adults, the median amount of compensation rose to $278,746, up from $253,000 in 2014, $234,000 in 2013, and $221,000 in 2011. These figures come from the MGMA survey, and the financial support figures above come from the separate SHM survey. That means it’s impossible to make firm conclusions about how the numbers do or don’t interrelate.
Don’t forget that surveys report all forms of compensation, including base, production, bonus, extra shifts, and other elements. This year’s $278,746 includes all the bonus dollars earned by each hospitalist in the survey. We can make a very rough guess at the bonus by multiplying the portion of total compensation tied to performance in the SHM survey (6%) by the total compensation ($278,746) from the MGMA survey, which comes to $13,397. But we still don’t know the portion of the total bonus dollars available that represents. My experience is that the total bonus dollars available is around $20,000 or more at most hospital medicine groups. Therefore, a doctor who earned $13,397 presumably didn’t meet all performance goals.
A Deeper Dive into Hospital Medicine Group Finances
It is really interesting to ponder where the dollars come from to fund higher hospitalist compensation if the financial support provided per FTE hasn’t increased. Perhaps hospitalists are generating more encounters, work relative value units (wRVUs), or professional fee collections?
Median professional fee collections were $213,000 this year, up from $151,000 in the prior survey two years ago. This increase could, in theory, fully fund the higher hospitalist compensation without the need for an increase in other sources of revenue.
So why are collections up? It could be because hospitalists are coding the average visit at a higher level: 2.02 wRVUs per encounter this year compared to 1.97 in 2014 and 1.91 in 2012. The survey can’t help distinguish whether this increase is because we’re seeing more complex patients or whether we’re improving our documentation to catch up with the complexity of the patients we’ve been seeing all along. I suspect it is both.
The increase in wRVUs per encounter, however, is offset by a continued downward trend in numbers of encounters: 1,684 this year compared to 1,850 in 2014 and 2,078 in 2012. The total wRVUs generated per hospitalist in a year stayed about the same at 4,247 compared to 4,298 in 2014.
The best explanation for why total collections are up would be that payor rates have increased. But Medicare, which accounts for about 60%–65% of the payor mix for most hospital medicine groups, hasn’t increased rates enough to explain this, and I’m not aware of other payor classes that have increased significantly. Another explanation could be that hospital medicine groups are simply doing a better job with billing and collections and other revenue-cycle management activities, resulting in increased revenue.
I guess it shouldn’t be surprising that some of the survey results don’t seem internally consistent. The data come from two different surveys, the response rate for each question varies, and other issues mean the survey just can’t provide that level of precision. We also need to keep in mind that analyses like I’ve provided here are only very rough explanations. But I think they’re still valuable to think about even if they don’t provide definitive answers. TH
Reference
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed August 9, 2016.
sSHM’s 2016 State of Hospital Medicine Report (SoHM) is now available, and it’s unquestionably the best source of detail regarding how hospital medicine groups are configured and operated.1
The SoHM is published in even years and combines data from two sources:
- Hospitalist data from Medical Group Management Association’s Physician Compensation and Productivity Survey. Within the SoHM, you will find the same figures for hospitalist compensation, production, and a few related metrics that are from the MGMA survey report.
- SHM’s survey of hospital medicine groups. This survey drills into significant detail on things like scope of clinical practice, staffing levels, work schedules, bonus metrics, CPT code distribution, roles for NPs and PAs, and the amount of financial support provided to the group.
There are several new topics in this year’s SoHM, including CME allowances, utilization of prolonged service codes, and charge capture methodologies being used by hospital medicine groups. My colleague, Leslie Flores, has been very involved in the survey for 10 years and has written a blog with more details.
One Caveat …
The mix of survey respondents varies and includes a much larger portion of hospital medicine groups employed by multi-state management companies than prior surveys. Even if a parameter hasn’t changed for any hospitalist group, the fact that responses come from different contingents of the hospitalist workforce can result in a different result from one survey to the next. It is difficult to be certain if variations across successive surveys reflect a real change in the marketplace or are a function of variation in the respondent population.
Now let’s review and analyze some of this year’s survey findings for hospital medicine groups caring for adults:
Financial Support Stayed Flat
The amount of financial support provided to a hospital medicine group per FTE has increased significantly in every prior survey. This money typically comes from the hospital that the hospital medicine group serves and is sometimes referred to as the “subsidy.” For hospital medicine groups serving adults, it was $139,000 in 2012 and $156,000 in 2014.
The current survey showed a median of $157,500, essentially unchanged from two years prior. This is either an aberration in the survey (e.g., a result of a different survey population) or an indicator that this amount has begun to level off. Clearly, there is an upper limit to the amount of financial support the marketplace can support, but from my experience working with hospitalist groups around the country, I haven’t seen evidence that we’ve reached that point. I suspect it is an aberration and future surveys will show a continued rising trend, though perhaps not as rapidly as in years past.
Compensation Method Is Evolving
A mean of 14.7% of compensation was tied to production, up from around 10% in prior surveys. And the portion tied to performance (e.g., patient satisfaction, quality metrics) was unchanged at 6%. It’s interesting that despite proliferation of pay-for-performance programs and increasing emphasis on quality and value, it is the productivity portion of compensation that increased. It’s hard to know if that is a meaningful trend.
Compensation Amount Continues to Increase
For hospitalists caring for adults, the median amount of compensation rose to $278,746, up from $253,000 in 2014, $234,000 in 2013, and $221,000 in 2011. These figures come from the MGMA survey, and the financial support figures above come from the separate SHM survey. That means it’s impossible to make firm conclusions about how the numbers do or don’t interrelate.
Don’t forget that surveys report all forms of compensation, including base, production, bonus, extra shifts, and other elements. This year’s $278,746 includes all the bonus dollars earned by each hospitalist in the survey. We can make a very rough guess at the bonus by multiplying the portion of total compensation tied to performance in the SHM survey (6%) by the total compensation ($278,746) from the MGMA survey, which comes to $13,397. But we still don’t know the portion of the total bonus dollars available that represents. My experience is that the total bonus dollars available is around $20,000 or more at most hospital medicine groups. Therefore, a doctor who earned $13,397 presumably didn’t meet all performance goals.
A Deeper Dive into Hospital Medicine Group Finances
It is really interesting to ponder where the dollars come from to fund higher hospitalist compensation if the financial support provided per FTE hasn’t increased. Perhaps hospitalists are generating more encounters, work relative value units (wRVUs), or professional fee collections?
Median professional fee collections were $213,000 this year, up from $151,000 in the prior survey two years ago. This increase could, in theory, fully fund the higher hospitalist compensation without the need for an increase in other sources of revenue.
So why are collections up? It could be because hospitalists are coding the average visit at a higher level: 2.02 wRVUs per encounter this year compared to 1.97 in 2014 and 1.91 in 2012. The survey can’t help distinguish whether this increase is because we’re seeing more complex patients or whether we’re improving our documentation to catch up with the complexity of the patients we’ve been seeing all along. I suspect it is both.
The increase in wRVUs per encounter, however, is offset by a continued downward trend in numbers of encounters: 1,684 this year compared to 1,850 in 2014 and 2,078 in 2012. The total wRVUs generated per hospitalist in a year stayed about the same at 4,247 compared to 4,298 in 2014.
The best explanation for why total collections are up would be that payor rates have increased. But Medicare, which accounts for about 60%–65% of the payor mix for most hospital medicine groups, hasn’t increased rates enough to explain this, and I’m not aware of other payor classes that have increased significantly. Another explanation could be that hospital medicine groups are simply doing a better job with billing and collections and other revenue-cycle management activities, resulting in increased revenue.
I guess it shouldn’t be surprising that some of the survey results don’t seem internally consistent. The data come from two different surveys, the response rate for each question varies, and other issues mean the survey just can’t provide that level of precision. We also need to keep in mind that analyses like I’ve provided here are only very rough explanations. But I think they’re still valuable to think about even if they don’t provide definitive answers. TH
Reference
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed August 9, 2016.
Hospital Mobility Program Maintains Older Patients’ Mobility after Discharge
Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.
Study design: Randomized, single-blinded controlled trial.
Setting: Birmingham Veterans Affairs Medical Center, Alabama.
Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.
One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.
Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.
Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.
Short Take
Topical NSAIDs Effective for Back Pain
Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.
Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.
Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.
Study design: Randomized, single-blinded controlled trial.
Setting: Birmingham Veterans Affairs Medical Center, Alabama.
Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.
One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.
Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.
Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.
Short Take
Topical NSAIDs Effective for Back Pain
Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.
Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.
Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.
Study design: Randomized, single-blinded controlled trial.
Setting: Birmingham Veterans Affairs Medical Center, Alabama.
Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.
One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.
Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.
Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.
Short Take
Topical NSAIDs Effective for Back Pain
Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.
Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.
Daily Round Checklists in ICU Setting Don’t Reduce Mortality
Background: Checklists, goal assessment, and clinician prompting have shown promise in improving communication, care-process adherence, and clinical outcomes in ICUs and acute-care settings, but existing studies are limited by nonrandomized design and high-income settings.
Study design: Cluster randomized trial.
Setting: 118 academic and nonacademic ICUs in Brazil.
Synopsis: Researchers randomized 6,761 patients to a quality improvement (QI) intervention with daily round checklists, goal setting, and clinician prompting. Analyses were adjusted for patient’s severity of illness and the ICU’s adjusted mortality ratio. There was no significant difference in in-hospital mortality (odds ratio, 1.02; 95% CI, 0.82–1.26). The QI intervention had no effect on 10 secondary clinical outcomes (e.g., ventilator-associated pneumonia). The intervention improved adherence with four of seven care processes (e.g., use of low tidal volumes) and two of six factors of the safety climate. After adjusting for multiple comparisons, only urinary catheter use remained statistically significant.
Strengths of this study are the large number of ICUs involved and a high rate of QI adherence. Limitations include the setting in a resource-constrained nation, limited success with adopting changes in care processes, and relatively short intervention period of six months.
Bottom line: In a large Brazilian randomized control trial, implementation of daily round checklists, along with goal setting and clinician prompting, did not change in-hospital mortality. It is possible that a longer intervention period would have found improved outcomes.
Citation: Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480-1490.
Short Take
More Restrictions on Fluoroquinolones
The U.S. Food and Drug Administration has recommended avoidance of fluoroquinolone drugs, which are often used for patients with acute bronchitis, acute sinusitis, and uncomplicated UTI, due to the potential of serious side effects. Exceptions should be made for cases with no other treatment options.
Citation: Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. U.S. Food and Drug Administration website.
Background: Checklists, goal assessment, and clinician prompting have shown promise in improving communication, care-process adherence, and clinical outcomes in ICUs and acute-care settings, but existing studies are limited by nonrandomized design and high-income settings.
Study design: Cluster randomized trial.
Setting: 118 academic and nonacademic ICUs in Brazil.
Synopsis: Researchers randomized 6,761 patients to a quality improvement (QI) intervention with daily round checklists, goal setting, and clinician prompting. Analyses were adjusted for patient’s severity of illness and the ICU’s adjusted mortality ratio. There was no significant difference in in-hospital mortality (odds ratio, 1.02; 95% CI, 0.82–1.26). The QI intervention had no effect on 10 secondary clinical outcomes (e.g., ventilator-associated pneumonia). The intervention improved adherence with four of seven care processes (e.g., use of low tidal volumes) and two of six factors of the safety climate. After adjusting for multiple comparisons, only urinary catheter use remained statistically significant.
Strengths of this study are the large number of ICUs involved and a high rate of QI adherence. Limitations include the setting in a resource-constrained nation, limited success with adopting changes in care processes, and relatively short intervention period of six months.
Bottom line: In a large Brazilian randomized control trial, implementation of daily round checklists, along with goal setting and clinician prompting, did not change in-hospital mortality. It is possible that a longer intervention period would have found improved outcomes.
Citation: Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480-1490.
Short Take
More Restrictions on Fluoroquinolones
The U.S. Food and Drug Administration has recommended avoidance of fluoroquinolone drugs, which are often used for patients with acute bronchitis, acute sinusitis, and uncomplicated UTI, due to the potential of serious side effects. Exceptions should be made for cases with no other treatment options.
Citation: Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. U.S. Food and Drug Administration website.
Background: Checklists, goal assessment, and clinician prompting have shown promise in improving communication, care-process adherence, and clinical outcomes in ICUs and acute-care settings, but existing studies are limited by nonrandomized design and high-income settings.
Study design: Cluster randomized trial.
Setting: 118 academic and nonacademic ICUs in Brazil.
Synopsis: Researchers randomized 6,761 patients to a quality improvement (QI) intervention with daily round checklists, goal setting, and clinician prompting. Analyses were adjusted for patient’s severity of illness and the ICU’s adjusted mortality ratio. There was no significant difference in in-hospital mortality (odds ratio, 1.02; 95% CI, 0.82–1.26). The QI intervention had no effect on 10 secondary clinical outcomes (e.g., ventilator-associated pneumonia). The intervention improved adherence with four of seven care processes (e.g., use of low tidal volumes) and two of six factors of the safety climate. After adjusting for multiple comparisons, only urinary catheter use remained statistically significant.
Strengths of this study are the large number of ICUs involved and a high rate of QI adherence. Limitations include the setting in a resource-constrained nation, limited success with adopting changes in care processes, and relatively short intervention period of six months.
Bottom line: In a large Brazilian randomized control trial, implementation of daily round checklists, along with goal setting and clinician prompting, did not change in-hospital mortality. It is possible that a longer intervention period would have found improved outcomes.
Citation: Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480-1490.
Short Take
More Restrictions on Fluoroquinolones
The U.S. Food and Drug Administration has recommended avoidance of fluoroquinolone drugs, which are often used for patients with acute bronchitis, acute sinusitis, and uncomplicated UTI, due to the potential of serious side effects. Exceptions should be made for cases with no other treatment options.
Citation: Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. U.S. Food and Drug Administration website.
Working Towards Fewer Delirium Cases
Delirium may be preventable among the elderly population, according to an abstract presented at the 2016 SHM annual meeting.1
The development of delirium involves an interrelationship between predisposing factors and precipitating factors in vulnerable patients. In 2015, a pilot project was conducted at Guthrie Robert Packer Hospital in Sayre, Penn., that included post-orthopedic surgery patients 60 years of age and older and patients with dementia at baseline cognitive function on admission.
The focus was on managing five risk factors: cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and medications. The nurses and residents caring for the patients were educated about methods that were proven to decrease the incidence of delirium. These include:
- Using clocks and blinds to help restore circadian balance
- Encouraging cognitive stimulation and regular visits from family and friends
- Facilitating physiologic sleep with avoidance of interruption during sleeping hours
- Initiating early mobilization and minimizing use of physical restraints
The result? In the pre-intervention group, 48% of the patients were found to have delirium with different precipitating factors. In the post-intervention group, the incidence decreased to 26.9%.
“This project was undertaken to increase the awareness of a non-costly, easy, and available intervention to prevent delirium,” says lead author Marcelle Meseeha, MD, a hospitalist at Guthrie Robert Packer Hospital. “Post-intervention study showed that the incidence of delirium has significantly decreased applying simple interventions. These familiar practices should be a mandatory process or a reminder in electronic health records. Also, education of providers and nursing staff must be an ongoing process. This will help reduce the incidence of delirium with its deleterious sequelae.” TH
Reference
- Meseeha M, Attia M. Ways to reduce incidence of hospital ward-acquired delirium; a quality improvement project [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed July 18, 2016.
Delirium may be preventable among the elderly population, according to an abstract presented at the 2016 SHM annual meeting.1
The development of delirium involves an interrelationship between predisposing factors and precipitating factors in vulnerable patients. In 2015, a pilot project was conducted at Guthrie Robert Packer Hospital in Sayre, Penn., that included post-orthopedic surgery patients 60 years of age and older and patients with dementia at baseline cognitive function on admission.
The focus was on managing five risk factors: cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and medications. The nurses and residents caring for the patients were educated about methods that were proven to decrease the incidence of delirium. These include:
- Using clocks and blinds to help restore circadian balance
- Encouraging cognitive stimulation and regular visits from family and friends
- Facilitating physiologic sleep with avoidance of interruption during sleeping hours
- Initiating early mobilization and minimizing use of physical restraints
The result? In the pre-intervention group, 48% of the patients were found to have delirium with different precipitating factors. In the post-intervention group, the incidence decreased to 26.9%.
“This project was undertaken to increase the awareness of a non-costly, easy, and available intervention to prevent delirium,” says lead author Marcelle Meseeha, MD, a hospitalist at Guthrie Robert Packer Hospital. “Post-intervention study showed that the incidence of delirium has significantly decreased applying simple interventions. These familiar practices should be a mandatory process or a reminder in electronic health records. Also, education of providers and nursing staff must be an ongoing process. This will help reduce the incidence of delirium with its deleterious sequelae.” TH
Reference
- Meseeha M, Attia M. Ways to reduce incidence of hospital ward-acquired delirium; a quality improvement project [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed July 18, 2016.
Delirium may be preventable among the elderly population, according to an abstract presented at the 2016 SHM annual meeting.1
The development of delirium involves an interrelationship between predisposing factors and precipitating factors in vulnerable patients. In 2015, a pilot project was conducted at Guthrie Robert Packer Hospital in Sayre, Penn., that included post-orthopedic surgery patients 60 years of age and older and patients with dementia at baseline cognitive function on admission.
The focus was on managing five risk factors: cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and medications. The nurses and residents caring for the patients were educated about methods that were proven to decrease the incidence of delirium. These include:
- Using clocks and blinds to help restore circadian balance
- Encouraging cognitive stimulation and regular visits from family and friends
- Facilitating physiologic sleep with avoidance of interruption during sleeping hours
- Initiating early mobilization and minimizing use of physical restraints
The result? In the pre-intervention group, 48% of the patients were found to have delirium with different precipitating factors. In the post-intervention group, the incidence decreased to 26.9%.
“This project was undertaken to increase the awareness of a non-costly, easy, and available intervention to prevent delirium,” says lead author Marcelle Meseeha, MD, a hospitalist at Guthrie Robert Packer Hospital. “Post-intervention study showed that the incidence of delirium has significantly decreased applying simple interventions. These familiar practices should be a mandatory process or a reminder in electronic health records. Also, education of providers and nursing staff must be an ongoing process. This will help reduce the incidence of delirium with its deleterious sequelae.” TH
Reference
- Meseeha M, Attia M. Ways to reduce incidence of hospital ward-acquired delirium; a quality improvement project [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed July 18, 2016.
LETTER: 6 Tips When Practicing Telemedicine
In early 2014, I decided to use the six state licenses I had obtained as a locum tenens physician to start practicing telemedicine. Since then, I have worked with several telemedicine platforms. I have found that telemedicine companies differ dramatically in their overall ease of use for the provider. Here are my top tips for deciding which telemedicine company to work with.
- Technology support: Telemedicine is dependent on technology. If it is difficult to get help from tech support, do not credential with the company. Tech support is your lifeline to your patients. Make sure you can get help right away if you are having problems finishing or starting a consult. Companies that send automatic emails saying they will get back to you within 24 hours are the most difficult to work with.
- Nursing support: All of the telemedicine companies that I have worked with have amazing nurses, but some are overwhelmed with work. Telemedicine nurses are able to connect to your patients via direct callback numbers in a way that you cannot connect. They are able to call in prescriptions to pharmacies if the platform is down or if the patient put in the wrong pharmacy information. Make sure that the company has a nurse that is able to call you back right away. A few telemedicine companies are understaffed with nurses, and it can take hours for a callback. If the key to telemedicine is volume, this is frustrating to deal with.
- Chief complaints: Many telemedicine companies are moving away from making the “chief complaint” visible to providers before choosing to take the consult. For me, this is a big red flag. It can be as simple as, “I have a cold.” I like this because if I see a patient who says, “I have abdominal pain,” I know to triage them first.
- Volume: Telemedicine is great for staying connected to outpatient medicine. If you are looking to work on a telemedicine platform for your main source of income, then volume is key. A lot of telemedicine companies will tell you how many calls they get per day; the key question is how many calls they get for the states that you are licensed in and how many providers they have licensed in those states. If you want higher volume, then ask if they will pay for your license in states with higher needs (some will). If you are willing to pay to be licensed in additional states, make sure the volume is high enough to make that extra out-of-pocket cost worth it.
- Malpractice coverage: Many companies provide malpractice coverage as part of their credentialing package. If they do not, make sure your malpractice coverage covers you for telemedicine.
- Documentation: Documentation during your telemedicine consult is arguably even more important than in an outpatient visit. Everything is on the phone or by video, so make sure, in the subjective area, that you are quoting what the patient is telling you. You are not able to do a physical exam, so your recommendations will be based on what the patient is saying.
Have fun! Telemedicine has been really enjoyable for me. I like being able to have the time to educate my patients about things like antibiotics. I enjoy the technological aspects and understanding all of the different platforms. Telemedicine gives you a unique opportunity to practice your skills from the comfort of your own home. TH
In early 2014, I decided to use the six state licenses I had obtained as a locum tenens physician to start practicing telemedicine. Since then, I have worked with several telemedicine platforms. I have found that telemedicine companies differ dramatically in their overall ease of use for the provider. Here are my top tips for deciding which telemedicine company to work with.
- Technology support: Telemedicine is dependent on technology. If it is difficult to get help from tech support, do not credential with the company. Tech support is your lifeline to your patients. Make sure you can get help right away if you are having problems finishing or starting a consult. Companies that send automatic emails saying they will get back to you within 24 hours are the most difficult to work with.
- Nursing support: All of the telemedicine companies that I have worked with have amazing nurses, but some are overwhelmed with work. Telemedicine nurses are able to connect to your patients via direct callback numbers in a way that you cannot connect. They are able to call in prescriptions to pharmacies if the platform is down or if the patient put in the wrong pharmacy information. Make sure that the company has a nurse that is able to call you back right away. A few telemedicine companies are understaffed with nurses, and it can take hours for a callback. If the key to telemedicine is volume, this is frustrating to deal with.
- Chief complaints: Many telemedicine companies are moving away from making the “chief complaint” visible to providers before choosing to take the consult. For me, this is a big red flag. It can be as simple as, “I have a cold.” I like this because if I see a patient who says, “I have abdominal pain,” I know to triage them first.
- Volume: Telemedicine is great for staying connected to outpatient medicine. If you are looking to work on a telemedicine platform for your main source of income, then volume is key. A lot of telemedicine companies will tell you how many calls they get per day; the key question is how many calls they get for the states that you are licensed in and how many providers they have licensed in those states. If you want higher volume, then ask if they will pay for your license in states with higher needs (some will). If you are willing to pay to be licensed in additional states, make sure the volume is high enough to make that extra out-of-pocket cost worth it.
- Malpractice coverage: Many companies provide malpractice coverage as part of their credentialing package. If they do not, make sure your malpractice coverage covers you for telemedicine.
- Documentation: Documentation during your telemedicine consult is arguably even more important than in an outpatient visit. Everything is on the phone or by video, so make sure, in the subjective area, that you are quoting what the patient is telling you. You are not able to do a physical exam, so your recommendations will be based on what the patient is saying.
Have fun! Telemedicine has been really enjoyable for me. I like being able to have the time to educate my patients about things like antibiotics. I enjoy the technological aspects and understanding all of the different platforms. Telemedicine gives you a unique opportunity to practice your skills from the comfort of your own home. TH
In early 2014, I decided to use the six state licenses I had obtained as a locum tenens physician to start practicing telemedicine. Since then, I have worked with several telemedicine platforms. I have found that telemedicine companies differ dramatically in their overall ease of use for the provider. Here are my top tips for deciding which telemedicine company to work with.
- Technology support: Telemedicine is dependent on technology. If it is difficult to get help from tech support, do not credential with the company. Tech support is your lifeline to your patients. Make sure you can get help right away if you are having problems finishing or starting a consult. Companies that send automatic emails saying they will get back to you within 24 hours are the most difficult to work with.
- Nursing support: All of the telemedicine companies that I have worked with have amazing nurses, but some are overwhelmed with work. Telemedicine nurses are able to connect to your patients via direct callback numbers in a way that you cannot connect. They are able to call in prescriptions to pharmacies if the platform is down or if the patient put in the wrong pharmacy information. Make sure that the company has a nurse that is able to call you back right away. A few telemedicine companies are understaffed with nurses, and it can take hours for a callback. If the key to telemedicine is volume, this is frustrating to deal with.
- Chief complaints: Many telemedicine companies are moving away from making the “chief complaint” visible to providers before choosing to take the consult. For me, this is a big red flag. It can be as simple as, “I have a cold.” I like this because if I see a patient who says, “I have abdominal pain,” I know to triage them first.
- Volume: Telemedicine is great for staying connected to outpatient medicine. If you are looking to work on a telemedicine platform for your main source of income, then volume is key. A lot of telemedicine companies will tell you how many calls they get per day; the key question is how many calls they get for the states that you are licensed in and how many providers they have licensed in those states. If you want higher volume, then ask if they will pay for your license in states with higher needs (some will). If you are willing to pay to be licensed in additional states, make sure the volume is high enough to make that extra out-of-pocket cost worth it.
- Malpractice coverage: Many companies provide malpractice coverage as part of their credentialing package. If they do not, make sure your malpractice coverage covers you for telemedicine.
- Documentation: Documentation during your telemedicine consult is arguably even more important than in an outpatient visit. Everything is on the phone or by video, so make sure, in the subjective area, that you are quoting what the patient is telling you. You are not able to do a physical exam, so your recommendations will be based on what the patient is saying.
Have fun! Telemedicine has been really enjoyable for me. I like being able to have the time to educate my patients about things like antibiotics. I enjoy the technological aspects and understanding all of the different platforms. Telemedicine gives you a unique opportunity to practice your skills from the comfort of your own home. TH
Preorder 2016 State of Hospital Medicine Report
The State of Hospital Medicine Report (SoHM) is the most comprehensive survey of hospital medicine in the country and provides current data on hospitalist compensation and productivity, plus covers practice demographics, staffing levels, staff growth, and compensation models.
Don’t miss out on getting your copy when it becomes available. Order now at www.hospitalmedicine.org/survey and be notified directly when the report is released.
The State of Hospital Medicine Report (SoHM) is the most comprehensive survey of hospital medicine in the country and provides current data on hospitalist compensation and productivity, plus covers practice demographics, staffing levels, staff growth, and compensation models.
Don’t miss out on getting your copy when it becomes available. Order now at www.hospitalmedicine.org/survey and be notified directly when the report is released.
The State of Hospital Medicine Report (SoHM) is the most comprehensive survey of hospital medicine in the country and provides current data on hospitalist compensation and productivity, plus covers practice demographics, staffing levels, staff growth, and compensation models.
Don’t miss out on getting your copy when it becomes available. Order now at www.hospitalmedicine.org/survey and be notified directly when the report is released.
Last Call to Participate in SHM’s Engagement Benchmarking Survey
One of the most important questions for leaders of hospital medicine groups is, “How can I measure the level of engagement of my hospitalists?” Measuring hospitalist engagement can be difficult, and many leaders are not satisfied with the tools they currently have at their disposal.
SHM developed an Engagement Benchmarking Service that evaluates care quality, autonomy, effective motivation, burnout risk, and more. You can see your standardization scores ranked against national benchmarks to help you determine what’s working well and what needs improvement.
Recruiting ends at the end of September, so register now for the next cohort at www.hospitalmedicine.org/pmad3.
One of the most important questions for leaders of hospital medicine groups is, “How can I measure the level of engagement of my hospitalists?” Measuring hospitalist engagement can be difficult, and many leaders are not satisfied with the tools they currently have at their disposal.
SHM developed an Engagement Benchmarking Service that evaluates care quality, autonomy, effective motivation, burnout risk, and more. You can see your standardization scores ranked against national benchmarks to help you determine what’s working well and what needs improvement.
Recruiting ends at the end of September, so register now for the next cohort at www.hospitalmedicine.org/pmad3.
One of the most important questions for leaders of hospital medicine groups is, “How can I measure the level of engagement of my hospitalists?” Measuring hospitalist engagement can be difficult, and many leaders are not satisfied with the tools they currently have at their disposal.
SHM developed an Engagement Benchmarking Service that evaluates care quality, autonomy, effective motivation, burnout risk, and more. You can see your standardization scores ranked against national benchmarks to help you determine what’s working well and what needs improvement.
Recruiting ends at the end of September, so register now for the next cohort at www.hospitalmedicine.org/pmad3.
Nonemergency Use of Antipsychotics in Patients with Dementia
Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.
Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.
Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.
When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.
Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).
Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.
Short Take
Colistin-Resistant E. coli in the U.S.
The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.
Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.
Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.
Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.
When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.
Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).
Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.
Short Take
Colistin-Resistant E. coli in the U.S.
The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.
Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.
Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.
Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.
When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.
Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).
Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.
Short Take
Colistin-Resistant E. coli in the U.S.
The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.
Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.