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CT Scans Reliable Determinants of Blunt Trauma
NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.
"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.
"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.
Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.
Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.
Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.
Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.
CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.
Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).
"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.
"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."
"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.
"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."
"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."
"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."
They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"
Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."
"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."
"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."
"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."
Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."
SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5
JAMA Surg 2016.
NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.
"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.
"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.
Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.
Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.
Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.
Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.
CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.
Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).
"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.
"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."
"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.
"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."
"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."
"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."
They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"
Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."
"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."
"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."
"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."
Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."
SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5
JAMA Surg 2016.
NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.
"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.
"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.
Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.
Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.
Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.
Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.
CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.
Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).
"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.
"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."
"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.
"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."
"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."
"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."
They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"
Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."
"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."
"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."
"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."
Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."
SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5
JAMA Surg 2016.
Education, Networking Opportunities Inspire Arizona Hospitalist Vishal Verma, MD, to Start New SHM Chapter
This month, The Hospitalist spotlights Vishal Verma, MD, medical director of the hospitalist program at 4C Medical Group in Scottsdale, Ariz. In addition to being an active SHM member and regular attendee at SHM meetings, Dr. Verma recently purchased a group membership for his hospitalist team. He also started an Arizona chapter of SHM, based on his positive experiences with SHM. He recently spoke with The Hospitalist to share his path to hospital medicine and his inspiration to expand the society’s reach in Arizona.
Question: How did you arrive at a career in hospital medicine?
Answer: After finishing my medical school training at Kasturba Medical College in Manipal, India, I traveled to the United States to further my education and begin my internship and residency. I started my internship in internal medicine at a downtown Brooklyn, N.Y., hospital in 2006. Internship year, though often considered to be a hectic and laborious year, was when I learned for the first time how to care for hospitalized patients. I was chosen by the chief residents as intern of the month in my first month of training. This honor, and the experience of training in an inner-city hospital, further ignited my passion to practice medicine.
It was during my time as an intern and resident when I fully realized the critical role hospitalists play as the main coordinators of care and witnessed their influence on care outcomes. I later served as chief medical resident and was elected by my fellow residents as president of house staff. I was also elected as vice president of the Committee of Interns and Residents (CIR) and served on CIR’s National Executive Board, where I passionately advocated for my patients and fellow colleagues. Serving in various roles provided me with an in-depth knowledge of hospital medicine and helped me build it as my career.
Q: In your current role, how does your membership with SHM help you improve quality of patient care?
A: Our group consists of 14 hospitalists who serve in two community hospitals. Being a member of SHM for many years has been a rewarding experience as it keeps me informed about changes and advances in hospital medicine. Through the Journal of Hospital Medicine, regular webinars, and SHM conferences and annual meetings, SHM helps us enrich our knowledge base on quality, performance, patient experience, coding, practice management, acute and post-acute care, and other aspects of hospital medicine.
At our recent visit to HM16 in San Diego, a few members of our team attended sessions on post-acute care and value-based reimbursements. At the sessions, we learned of the importance of stressing quality and engaging sub-acute rehab facilities in meaningful ways so as to improve the quality of care in skilled nursing facilities and also help to decrease the length of stay from 30 days to closer to 15 days. 4C Medical Group has implemented many suggestions from these lectures and is in the process of transforming our post-acute-care teams.
I also serve as a member of the board of directors for 4C Medical Group, where my association with SHM has helped me give valuable input while we manage the care of over 20,000 patients in acute, sub-acute, and home-based teams as well as outpatient clinics. SHM provides its members with a platform to sharpen their leadership skills and enables members to build a strong network among fellow leaders, which helps us learn about and share best practices, which translates to better quality of care.
For example, a recent presentation by SHM member Dr. Jesse Theisen-Toupal on inpatient management of opioid use disorder was an eye-opener. Learning about harm-reduction strategies for opioid misuse during the presentation was very helpful to us, and we shared the suggestions with our hospitalist team.
Q: What inspired you to start an Arizona chapter in Scottsdale and purchase a group membership for your team?
A: At HM16, I met Debra Beach, manager of membership and outreach programs at SHM, and we discussed how our company can align with SHM and bring our hospitalists on board as members to provide them with a greater network of resources. I was surprised that Arizona did not have a dedicated SHM chapter. Phoenix, one of the U.S.’s largest metropolitan areas, has many large hospital systems employing and contracting thousands of hospitalists. I saw an opening for a great opportunity to take the lead on developing an SHM chapter in Arizona with the support of my 4C colleagues. After discussing this opportunity with other hospitalist groups in Arizona, we came to the conclusion that it would benefit not only our team at 4C but hospitalists statewide.
I am confident that the Arizona chapter of SHM will not only be successful but soon will be contributing nationally to the hospitalist movement. Moreover, SHM will help keep our members educated and informed about the upcoming changes as we transition to a pay-for-performance model of reimbursement and any other healthcare system changes still to come.
I believe in the famous Chinese proverb, “A journey of a thousand miles begins with a single step.” We have taken the first step in our hospitalist group, and without a doubt, SHM’s journey in the state of Arizona shall be a success story. All our members are excited with this new beginning.
Q: How do you see hospital medicine evolving over the next 20 years?
A: 2016 has already been designated as the “Year of the Hospitalist.” I will take it a step further and predict that the next decade will be a decade of hospital medicine. Inpatient care is transforming at a rapid pace, and we need a dedicated and well-trained stream of doctors who are specialists in managing hospitalized patients. Care of hospitalized patients was once fragmented and costly; now with hospitalists as captains of the ship, care can be delivered in more comprehensive, cost-effective ways with better quality and increased performance. The introduction of a separate specialist billing code for hospitalists by the CMS is a step in the right direction.
In the next few years, I would enjoy seeing a separate board for hospitalists with hospital medicine’s own specialty certification. The potential for hospital medicine’s continued growth is tremendous, and I look forward to being a part of its future. TH
Brett Radler is SHM’s communications specialist.
This month, The Hospitalist spotlights Vishal Verma, MD, medical director of the hospitalist program at 4C Medical Group in Scottsdale, Ariz. In addition to being an active SHM member and regular attendee at SHM meetings, Dr. Verma recently purchased a group membership for his hospitalist team. He also started an Arizona chapter of SHM, based on his positive experiences with SHM. He recently spoke with The Hospitalist to share his path to hospital medicine and his inspiration to expand the society’s reach in Arizona.
Question: How did you arrive at a career in hospital medicine?
Answer: After finishing my medical school training at Kasturba Medical College in Manipal, India, I traveled to the United States to further my education and begin my internship and residency. I started my internship in internal medicine at a downtown Brooklyn, N.Y., hospital in 2006. Internship year, though often considered to be a hectic and laborious year, was when I learned for the first time how to care for hospitalized patients. I was chosen by the chief residents as intern of the month in my first month of training. This honor, and the experience of training in an inner-city hospital, further ignited my passion to practice medicine.
It was during my time as an intern and resident when I fully realized the critical role hospitalists play as the main coordinators of care and witnessed their influence on care outcomes. I later served as chief medical resident and was elected by my fellow residents as president of house staff. I was also elected as vice president of the Committee of Interns and Residents (CIR) and served on CIR’s National Executive Board, where I passionately advocated for my patients and fellow colleagues. Serving in various roles provided me with an in-depth knowledge of hospital medicine and helped me build it as my career.
Q: In your current role, how does your membership with SHM help you improve quality of patient care?
A: Our group consists of 14 hospitalists who serve in two community hospitals. Being a member of SHM for many years has been a rewarding experience as it keeps me informed about changes and advances in hospital medicine. Through the Journal of Hospital Medicine, regular webinars, and SHM conferences and annual meetings, SHM helps us enrich our knowledge base on quality, performance, patient experience, coding, practice management, acute and post-acute care, and other aspects of hospital medicine.
At our recent visit to HM16 in San Diego, a few members of our team attended sessions on post-acute care and value-based reimbursements. At the sessions, we learned of the importance of stressing quality and engaging sub-acute rehab facilities in meaningful ways so as to improve the quality of care in skilled nursing facilities and also help to decrease the length of stay from 30 days to closer to 15 days. 4C Medical Group has implemented many suggestions from these lectures and is in the process of transforming our post-acute-care teams.
I also serve as a member of the board of directors for 4C Medical Group, where my association with SHM has helped me give valuable input while we manage the care of over 20,000 patients in acute, sub-acute, and home-based teams as well as outpatient clinics. SHM provides its members with a platform to sharpen their leadership skills and enables members to build a strong network among fellow leaders, which helps us learn about and share best practices, which translates to better quality of care.
For example, a recent presentation by SHM member Dr. Jesse Theisen-Toupal on inpatient management of opioid use disorder was an eye-opener. Learning about harm-reduction strategies for opioid misuse during the presentation was very helpful to us, and we shared the suggestions with our hospitalist team.
Q: What inspired you to start an Arizona chapter in Scottsdale and purchase a group membership for your team?
A: At HM16, I met Debra Beach, manager of membership and outreach programs at SHM, and we discussed how our company can align with SHM and bring our hospitalists on board as members to provide them with a greater network of resources. I was surprised that Arizona did not have a dedicated SHM chapter. Phoenix, one of the U.S.’s largest metropolitan areas, has many large hospital systems employing and contracting thousands of hospitalists. I saw an opening for a great opportunity to take the lead on developing an SHM chapter in Arizona with the support of my 4C colleagues. After discussing this opportunity with other hospitalist groups in Arizona, we came to the conclusion that it would benefit not only our team at 4C but hospitalists statewide.
I am confident that the Arizona chapter of SHM will not only be successful but soon will be contributing nationally to the hospitalist movement. Moreover, SHM will help keep our members educated and informed about the upcoming changes as we transition to a pay-for-performance model of reimbursement and any other healthcare system changes still to come.
I believe in the famous Chinese proverb, “A journey of a thousand miles begins with a single step.” We have taken the first step in our hospitalist group, and without a doubt, SHM’s journey in the state of Arizona shall be a success story. All our members are excited with this new beginning.
Q: How do you see hospital medicine evolving over the next 20 years?
A: 2016 has already been designated as the “Year of the Hospitalist.” I will take it a step further and predict that the next decade will be a decade of hospital medicine. Inpatient care is transforming at a rapid pace, and we need a dedicated and well-trained stream of doctors who are specialists in managing hospitalized patients. Care of hospitalized patients was once fragmented and costly; now with hospitalists as captains of the ship, care can be delivered in more comprehensive, cost-effective ways with better quality and increased performance. The introduction of a separate specialist billing code for hospitalists by the CMS is a step in the right direction.
In the next few years, I would enjoy seeing a separate board for hospitalists with hospital medicine’s own specialty certification. The potential for hospital medicine’s continued growth is tremendous, and I look forward to being a part of its future. TH
Brett Radler is SHM’s communications specialist.
This month, The Hospitalist spotlights Vishal Verma, MD, medical director of the hospitalist program at 4C Medical Group in Scottsdale, Ariz. In addition to being an active SHM member and regular attendee at SHM meetings, Dr. Verma recently purchased a group membership for his hospitalist team. He also started an Arizona chapter of SHM, based on his positive experiences with SHM. He recently spoke with The Hospitalist to share his path to hospital medicine and his inspiration to expand the society’s reach in Arizona.
Question: How did you arrive at a career in hospital medicine?
Answer: After finishing my medical school training at Kasturba Medical College in Manipal, India, I traveled to the United States to further my education and begin my internship and residency. I started my internship in internal medicine at a downtown Brooklyn, N.Y., hospital in 2006. Internship year, though often considered to be a hectic and laborious year, was when I learned for the first time how to care for hospitalized patients. I was chosen by the chief residents as intern of the month in my first month of training. This honor, and the experience of training in an inner-city hospital, further ignited my passion to practice medicine.
It was during my time as an intern and resident when I fully realized the critical role hospitalists play as the main coordinators of care and witnessed their influence on care outcomes. I later served as chief medical resident and was elected by my fellow residents as president of house staff. I was also elected as vice president of the Committee of Interns and Residents (CIR) and served on CIR’s National Executive Board, where I passionately advocated for my patients and fellow colleagues. Serving in various roles provided me with an in-depth knowledge of hospital medicine and helped me build it as my career.
Q: In your current role, how does your membership with SHM help you improve quality of patient care?
A: Our group consists of 14 hospitalists who serve in two community hospitals. Being a member of SHM for many years has been a rewarding experience as it keeps me informed about changes and advances in hospital medicine. Through the Journal of Hospital Medicine, regular webinars, and SHM conferences and annual meetings, SHM helps us enrich our knowledge base on quality, performance, patient experience, coding, practice management, acute and post-acute care, and other aspects of hospital medicine.
At our recent visit to HM16 in San Diego, a few members of our team attended sessions on post-acute care and value-based reimbursements. At the sessions, we learned of the importance of stressing quality and engaging sub-acute rehab facilities in meaningful ways so as to improve the quality of care in skilled nursing facilities and also help to decrease the length of stay from 30 days to closer to 15 days. 4C Medical Group has implemented many suggestions from these lectures and is in the process of transforming our post-acute-care teams.
I also serve as a member of the board of directors for 4C Medical Group, where my association with SHM has helped me give valuable input while we manage the care of over 20,000 patients in acute, sub-acute, and home-based teams as well as outpatient clinics. SHM provides its members with a platform to sharpen their leadership skills and enables members to build a strong network among fellow leaders, which helps us learn about and share best practices, which translates to better quality of care.
For example, a recent presentation by SHM member Dr. Jesse Theisen-Toupal on inpatient management of opioid use disorder was an eye-opener. Learning about harm-reduction strategies for opioid misuse during the presentation was very helpful to us, and we shared the suggestions with our hospitalist team.
Q: What inspired you to start an Arizona chapter in Scottsdale and purchase a group membership for your team?
A: At HM16, I met Debra Beach, manager of membership and outreach programs at SHM, and we discussed how our company can align with SHM and bring our hospitalists on board as members to provide them with a greater network of resources. I was surprised that Arizona did not have a dedicated SHM chapter. Phoenix, one of the U.S.’s largest metropolitan areas, has many large hospital systems employing and contracting thousands of hospitalists. I saw an opening for a great opportunity to take the lead on developing an SHM chapter in Arizona with the support of my 4C colleagues. After discussing this opportunity with other hospitalist groups in Arizona, we came to the conclusion that it would benefit not only our team at 4C but hospitalists statewide.
I am confident that the Arizona chapter of SHM will not only be successful but soon will be contributing nationally to the hospitalist movement. Moreover, SHM will help keep our members educated and informed about the upcoming changes as we transition to a pay-for-performance model of reimbursement and any other healthcare system changes still to come.
I believe in the famous Chinese proverb, “A journey of a thousand miles begins with a single step.” We have taken the first step in our hospitalist group, and without a doubt, SHM’s journey in the state of Arizona shall be a success story. All our members are excited with this new beginning.
Q: How do you see hospital medicine evolving over the next 20 years?
A: 2016 has already been designated as the “Year of the Hospitalist.” I will take it a step further and predict that the next decade will be a decade of hospital medicine. Inpatient care is transforming at a rapid pace, and we need a dedicated and well-trained stream of doctors who are specialists in managing hospitalized patients. Care of hospitalized patients was once fragmented and costly; now with hospitalists as captains of the ship, care can be delivered in more comprehensive, cost-effective ways with better quality and increased performance. The introduction of a separate specialist billing code for hospitalists by the CMS is a step in the right direction.
In the next few years, I would enjoy seeing a separate board for hospitalists with hospital medicine’s own specialty certification. The potential for hospital medicine’s continued growth is tremendous, and I look forward to being a part of its future. TH
Brett Radler is SHM’s communications specialist.
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Register, book your hotel, and see the full course schedule at www.phmmeeting.org.
Brett Radler is SHM’s communications coordinator.
Register, book your hotel, and see the full course schedule at www.phmmeeting.org.
Brett Radler is SHM’s communications coordinator.
Register, book your hotel, and see the full course schedule at www.phmmeeting.org.
Brett Radler is SHM’s communications coordinator.
Is It Safe to Discharge a Patient with IDU History, PICC for Outpatient Antimicrobial Therapy?
Case
A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.
Background
Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.
A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.
The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3
The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5
No studies have compared OPAT therapy to inpatient therapy in IDU patients.
Back to the Case
Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.
Bottom Line
Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH
Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.
References
- Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
- Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
- Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
- Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
- Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.
Case
A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.
Background
Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.
A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.
The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3
The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5
No studies have compared OPAT therapy to inpatient therapy in IDU patients.
Back to the Case
Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.
Bottom Line
Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH
Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.
References
- Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
- Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
- Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
- Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
- Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.
Case
A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.
Background
Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.
A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.
The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3
The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5
No studies have compared OPAT therapy to inpatient therapy in IDU patients.
Back to the Case
Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.
Bottom Line
Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH
Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.
References
- Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
- Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
- Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
- Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
- Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.
LETTER: Point-of-Care Ultrasound: The (Sound) Wave of the Future for Hospitalists
Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.
POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.
With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.
For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.
POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.
POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.
It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.
Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.
Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter
Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.
POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.
With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.
For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.
POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.
POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.
It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.
Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.
Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter
Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.
POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.
With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.
For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.
POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.
POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.
It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.
Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.
Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter
MACRA Rule Offers Little Clarity for Hospitalists
Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.
However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.
The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.
For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”
MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.
What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.
To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.
Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).
Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.
However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.
“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”
CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.
The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”
The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.
Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.
“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.
Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.
Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.
“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.
To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH
Corrected version July 13, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.
However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.
The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.
For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”
MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.
What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.
To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.
Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).
Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.
However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.
“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”
CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.
The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”
The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.
Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.
“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.
Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.
Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.
“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.
To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH
Corrected version July 13, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.
However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.
The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.
For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”
MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.
What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.
To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.
Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).
Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.
However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.
“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”
CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.
The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”
The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.
Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.
“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.
Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.
Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.
“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.
To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH
Corrected version July 13, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Republicans Propose "A Better Way" to Regulate Healthcare
WASHINGTON - U.S. House of Representatives Speaker Paul Ryan unveiled a Republican healthcare agenda on Wednesday that would repeal Obamacare but keep some of its more popular provisions.
The proposal is part of Ryan's blueprint, titled "A Better Way," which offers a Republican alternative to the Democratic Party on policy issues ahead of the Nov. 8 election.
Earlier this month, Ryan, the country's highest-ranking elected Republican, released initiatives on national security and combating poverty. Proposals on regulation, tax reform and constitutional authority are expected in the coming weeks.
Republicans have challenged President Barack Obama's signature healthcare law, the Affordable Care Act, since it was enacted in 2010 after a bitter fight in Congress.
"Obamacare has limited choices for patients, driven up costs for consumers, and buried employers and health care providers under thousands of new regulations," a draft of the Ryan plan said. "This law cannot be fixed."
But Ryan's proposal would keep some popular aspects of the law, including not allowing people with pre-existing conditions to be denied coverage and permitting children to stay on their parents' coverage until age 26.
The Obama administration says some 20 million Americans have become insured as a result of the Affordable Care Act.
The Ryan plan recycles long-held Republican proposals like allowing consumers to buy health insurance across state lines, expanding the use of health savings accounts and giving states block grants to run the Medicaid program for the poor.
For people who do not get insurance through their jobs, the Republican plan would establish a refundable tax credit. Obamacare, by contrast, provides subsidies to some lower-income people to buy insurance if they do not qualify for Medicaid.
The Republican proposal would gradually increase the Medicare eligibility age, which currently is 65, to match that of the Social Security pension plan, which is 67 for people born in 1960 or later.
Like Obamacare's so-called Cadillac tax on expensive healthcare plans offered by employers, the Republican proposal would cap the tax deductibility of employer-based plans.
The Republican plan includes medical liability reform that would put a cap on non-economic damages awarded in lawsuits, a measure aimed at cutting overall healthcare costs.
Under Obamacare, many states expanded the number of people eligible for Medicaid. The Republican plan would allow states that decided to expand Medicaid before this year to keep the expansion, while preventing any new states from doing so.
WASHINGTON - U.S. House of Representatives Speaker Paul Ryan unveiled a Republican healthcare agenda on Wednesday that would repeal Obamacare but keep some of its more popular provisions.
The proposal is part of Ryan's blueprint, titled "A Better Way," which offers a Republican alternative to the Democratic Party on policy issues ahead of the Nov. 8 election.
Earlier this month, Ryan, the country's highest-ranking elected Republican, released initiatives on national security and combating poverty. Proposals on regulation, tax reform and constitutional authority are expected in the coming weeks.
Republicans have challenged President Barack Obama's signature healthcare law, the Affordable Care Act, since it was enacted in 2010 after a bitter fight in Congress.
"Obamacare has limited choices for patients, driven up costs for consumers, and buried employers and health care providers under thousands of new regulations," a draft of the Ryan plan said. "This law cannot be fixed."
But Ryan's proposal would keep some popular aspects of the law, including not allowing people with pre-existing conditions to be denied coverage and permitting children to stay on their parents' coverage until age 26.
The Obama administration says some 20 million Americans have become insured as a result of the Affordable Care Act.
The Ryan plan recycles long-held Republican proposals like allowing consumers to buy health insurance across state lines, expanding the use of health savings accounts and giving states block grants to run the Medicaid program for the poor.
For people who do not get insurance through their jobs, the Republican plan would establish a refundable tax credit. Obamacare, by contrast, provides subsidies to some lower-income people to buy insurance if they do not qualify for Medicaid.
The Republican proposal would gradually increase the Medicare eligibility age, which currently is 65, to match that of the Social Security pension plan, which is 67 for people born in 1960 or later.
Like Obamacare's so-called Cadillac tax on expensive healthcare plans offered by employers, the Republican proposal would cap the tax deductibility of employer-based plans.
The Republican plan includes medical liability reform that would put a cap on non-economic damages awarded in lawsuits, a measure aimed at cutting overall healthcare costs.
Under Obamacare, many states expanded the number of people eligible for Medicaid. The Republican plan would allow states that decided to expand Medicaid before this year to keep the expansion, while preventing any new states from doing so.
WASHINGTON - U.S. House of Representatives Speaker Paul Ryan unveiled a Republican healthcare agenda on Wednesday that would repeal Obamacare but keep some of its more popular provisions.
The proposal is part of Ryan's blueprint, titled "A Better Way," which offers a Republican alternative to the Democratic Party on policy issues ahead of the Nov. 8 election.
Earlier this month, Ryan, the country's highest-ranking elected Republican, released initiatives on national security and combating poverty. Proposals on regulation, tax reform and constitutional authority are expected in the coming weeks.
Republicans have challenged President Barack Obama's signature healthcare law, the Affordable Care Act, since it was enacted in 2010 after a bitter fight in Congress.
"Obamacare has limited choices for patients, driven up costs for consumers, and buried employers and health care providers under thousands of new regulations," a draft of the Ryan plan said. "This law cannot be fixed."
But Ryan's proposal would keep some popular aspects of the law, including not allowing people with pre-existing conditions to be denied coverage and permitting children to stay on their parents' coverage until age 26.
The Obama administration says some 20 million Americans have become insured as a result of the Affordable Care Act.
The Ryan plan recycles long-held Republican proposals like allowing consumers to buy health insurance across state lines, expanding the use of health savings accounts and giving states block grants to run the Medicaid program for the poor.
For people who do not get insurance through their jobs, the Republican plan would establish a refundable tax credit. Obamacare, by contrast, provides subsidies to some lower-income people to buy insurance if they do not qualify for Medicaid.
The Republican proposal would gradually increase the Medicare eligibility age, which currently is 65, to match that of the Social Security pension plan, which is 67 for people born in 1960 or later.
Like Obamacare's so-called Cadillac tax on expensive healthcare plans offered by employers, the Republican proposal would cap the tax deductibility of employer-based plans.
The Republican plan includes medical liability reform that would put a cap on non-economic damages awarded in lawsuits, a measure aimed at cutting overall healthcare costs.
Under Obamacare, many states expanded the number of people eligible for Medicaid. The Republican plan would allow states that decided to expand Medicaid before this year to keep the expansion, while preventing any new states from doing so.
Metformin Continues to Be First-Line Therapy for Type 2 Diabetes
Clinical question: Which medications are most safe and effective at managing type 2 diabetes?
Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.
Study design: Systematic review.
Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.
However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.
Bottom line: Metformin remains the first-line agent for type 2 diabetes management.
Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.
Short Take
Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization
Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.
Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.
Clinical question: Which medications are most safe and effective at managing type 2 diabetes?
Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.
Study design: Systematic review.
Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.
However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.
Bottom line: Metformin remains the first-line agent for type 2 diabetes management.
Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.
Short Take
Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization
Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.
Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.
Clinical question: Which medications are most safe and effective at managing type 2 diabetes?
Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.
Study design: Systematic review.
Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.
However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.
Bottom line: Metformin remains the first-line agent for type 2 diabetes management.
Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.
Short Take
Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization
Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.
Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.
Reevaluating Cardiovascular Risk after TIA
Clinical question: What is the prognosis of patients who have a TIA or minor stroke?
Background: Prior studies had estimated the risk in the three months following a TIA or minor stroke of having a stroke or acute coronary syndrome (ACS) as 12% to 20%, but this may not reflect the risk of modern patients receiving the current standards of care.
Study design: Prospective observational registry of patients with recent TIA or minor stroke.
Setting: International, including 21 countries.
Synopsis: Adults with recent TIA or minor stroke were included in this multi-center, international registry, and one-year outcomes were reported. At one year, the Kaplan-Meier estimated event rate for the combined outcome of stroke, ACS, or death from cardiovascular causes was 6.2%. The risk of the cardiovascular events was found to be lower than previously reported, suggesting an improvement in outcomes with current interventions. Elevated ABCD2 score, infarction seen on brain imaging, and large-artery atherosclerosis were each associated with higher risk.
Bottom line: Elevated ABCD2 score, brain imaging findings, and large-artery atherosclerosis suggest increased risk for recurrent stroke.
Citation: Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542.
Clinical question: What is the prognosis of patients who have a TIA or minor stroke?
Background: Prior studies had estimated the risk in the three months following a TIA or minor stroke of having a stroke or acute coronary syndrome (ACS) as 12% to 20%, but this may not reflect the risk of modern patients receiving the current standards of care.
Study design: Prospective observational registry of patients with recent TIA or minor stroke.
Setting: International, including 21 countries.
Synopsis: Adults with recent TIA or minor stroke were included in this multi-center, international registry, and one-year outcomes were reported. At one year, the Kaplan-Meier estimated event rate for the combined outcome of stroke, ACS, or death from cardiovascular causes was 6.2%. The risk of the cardiovascular events was found to be lower than previously reported, suggesting an improvement in outcomes with current interventions. Elevated ABCD2 score, infarction seen on brain imaging, and large-artery atherosclerosis were each associated with higher risk.
Bottom line: Elevated ABCD2 score, brain imaging findings, and large-artery atherosclerosis suggest increased risk for recurrent stroke.
Citation: Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542.
Clinical question: What is the prognosis of patients who have a TIA or minor stroke?
Background: Prior studies had estimated the risk in the three months following a TIA or minor stroke of having a stroke or acute coronary syndrome (ACS) as 12% to 20%, but this may not reflect the risk of modern patients receiving the current standards of care.
Study design: Prospective observational registry of patients with recent TIA or minor stroke.
Setting: International, including 21 countries.
Synopsis: Adults with recent TIA or minor stroke were included in this multi-center, international registry, and one-year outcomes were reported. At one year, the Kaplan-Meier estimated event rate for the combined outcome of stroke, ACS, or death from cardiovascular causes was 6.2%. The risk of the cardiovascular events was found to be lower than previously reported, suggesting an improvement in outcomes with current interventions. Elevated ABCD2 score, infarction seen on brain imaging, and large-artery atherosclerosis were each associated with higher risk.
Bottom line: Elevated ABCD2 score, brain imaging findings, and large-artery atherosclerosis suggest increased risk for recurrent stroke.
Citation: Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542.