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Clinical question: What strategies are effective in reducing contrast-induced nephropathy?

Bottom line: N-acetylcysteine plus intravenous fluids alone or in combination with a statin can prevent contrast-induced nephropathy (CIN). However, the strength of the evidence for these interventions is low. (LOE = 1b)

Reference: Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy. Ann Intern Med 2016;164(6):406-416.

Study design: Systematic review

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (ward only)

Synopsis

CIN is defined as an increase in serum creatinine of more than 25% or 0.5 mg/dL (44.2 umol/L) within 3 days of intravenous contrast administration. These investigators searched MEDLINE, EMBASE, and the Cochrane Library along with reference lists of relevant articles to find studies that evaluated use of N-acetylcysteine, sodium bicarbonate, sodium chloride, statins, or ascorbic acid to prevent CIN.

Two reviewers independently screened articles for eligibility, assessed each study's risk of bias, and graded the strength of evidence (SOE) for different comparisons. A total of 86 randomized controlled trials examining different strategies for CIN prevention were included. Ultimately, only 3 strategies were shown to have both a clinically important and statistically significant benefit: (1) low-dose N-acetylcysteine plus intravenous (IV) saline versus IV saline alone (pooled relative risk [RR] 0.75; 95% CI 0.63-0.89; low SOE), (2) N-acetylcysteine plus IV saline versus IV saline alone in patients receiving low-osmolar contrast media (pooled RR 0.69; 0.58-0.84; moderate SOE), and (3) statin plus N-acetylcysteine versus N-acetylcysteine alone (pooled RR 0.52; 0.29-0.93; low SOE). There were no statistically significant benefits seen with sodium bicarbonate or ascorbic acid.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: What strategies are effective in reducing contrast-induced nephropathy?

Bottom line: N-acetylcysteine plus intravenous fluids alone or in combination with a statin can prevent contrast-induced nephropathy (CIN). However, the strength of the evidence for these interventions is low. (LOE = 1b)

Reference: Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy. Ann Intern Med 2016;164(6):406-416.

Study design: Systematic review

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (ward only)

Synopsis

CIN is defined as an increase in serum creatinine of more than 25% or 0.5 mg/dL (44.2 umol/L) within 3 days of intravenous contrast administration. These investigators searched MEDLINE, EMBASE, and the Cochrane Library along with reference lists of relevant articles to find studies that evaluated use of N-acetylcysteine, sodium bicarbonate, sodium chloride, statins, or ascorbic acid to prevent CIN.

Two reviewers independently screened articles for eligibility, assessed each study's risk of bias, and graded the strength of evidence (SOE) for different comparisons. A total of 86 randomized controlled trials examining different strategies for CIN prevention were included. Ultimately, only 3 strategies were shown to have both a clinically important and statistically significant benefit: (1) low-dose N-acetylcysteine plus intravenous (IV) saline versus IV saline alone (pooled relative risk [RR] 0.75; 95% CI 0.63-0.89; low SOE), (2) N-acetylcysteine plus IV saline versus IV saline alone in patients receiving low-osmolar contrast media (pooled RR 0.69; 0.58-0.84; moderate SOE), and (3) statin plus N-acetylcysteine versus N-acetylcysteine alone (pooled RR 0.52; 0.29-0.93; low SOE). There were no statistically significant benefits seen with sodium bicarbonate or ascorbic acid.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: What strategies are effective in reducing contrast-induced nephropathy?

Bottom line: N-acetylcysteine plus intravenous fluids alone or in combination with a statin can prevent contrast-induced nephropathy (CIN). However, the strength of the evidence for these interventions is low. (LOE = 1b)

Reference: Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy. Ann Intern Med 2016;164(6):406-416.

Study design: Systematic review

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (ward only)

Synopsis

CIN is defined as an increase in serum creatinine of more than 25% or 0.5 mg/dL (44.2 umol/L) within 3 days of intravenous contrast administration. These investigators searched MEDLINE, EMBASE, and the Cochrane Library along with reference lists of relevant articles to find studies that evaluated use of N-acetylcysteine, sodium bicarbonate, sodium chloride, statins, or ascorbic acid to prevent CIN.

Two reviewers independently screened articles for eligibility, assessed each study's risk of bias, and graded the strength of evidence (SOE) for different comparisons. A total of 86 randomized controlled trials examining different strategies for CIN prevention were included. Ultimately, only 3 strategies were shown to have both a clinically important and statistically significant benefit: (1) low-dose N-acetylcysteine plus intravenous (IV) saline versus IV saline alone (pooled relative risk [RR] 0.75; 95% CI 0.63-0.89; low SOE), (2) N-acetylcysteine plus IV saline versus IV saline alone in patients receiving low-osmolar contrast media (pooled RR 0.69; 0.58-0.84; moderate SOE), and (3) statin plus N-acetylcysteine versus N-acetylcysteine alone (pooled RR 0.52; 0.29-0.93; low SOE). There were no statistically significant benefits seen with sodium bicarbonate or ascorbic acid.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of high-flow oxygen therapy for 24 hours following extubation reduce the risk of reintubation in low-risk patients?

Bottom line: Using high-flow nasal cannula oxygen therapy for 24 hours following extubation of patients who are already at low risk of reintubation further reduces the risk of reintubation. You would need to treat 14 patients with high-flow therapy to prevent reintubation in one patient. (LOE = 1b)

Reference: Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA 2016;315(13):1354-1361.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis

These investigators recruited mechanically ventilated adult patients who were ready for extubation and who met the criteria for low risk for reintubation. Low risk was defined as: younger than 65 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score of less than 12; fewer than 2 comorbidities; body mass index of less than 30; ability to manage secretions; simple weaning; and the absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency issues, and prolonged mechanical ventilation.

Using concealed allocation, these patients were randomized to receive either conventional oxygen therapy or high-flow oxygen therapy for 24 hours following extubation. Conventional oxygen therapy was continued in both groups after 24 hours as needed. The 2 groups had a mean age of 51 years and similar APACHE scores at baseline. The use of high-flow oxygen therapy reduced the rate of reintubation within 72 hours from 12.2% to 4.9% (absolute difference 7.2%; 95% CI 2.5%-12.2%; number needed to treat [NNT] = 14; P = .004). There were no significant differences detected in the 2 groups in secondary outcomes including time to reintubation or hospital length of stay. Notably, the study population had a high proportion of surgical and neurocritical patients, resulting in one-third of the reintubations occurring because of nonrespiratory causes such as repeat surgery or altered mental status. When the analysis was limited to only the respiratory-related intubations, the reduced risk of reintubation persisted in the high-flow oxygen group (1.5% vs 8.7%; NNT = 14; P = .001).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of high-flow oxygen therapy for 24 hours following extubation reduce the risk of reintubation in low-risk patients?

Bottom line: Using high-flow nasal cannula oxygen therapy for 24 hours following extubation of patients who are already at low risk of reintubation further reduces the risk of reintubation. You would need to treat 14 patients with high-flow therapy to prevent reintubation in one patient. (LOE = 1b)

Reference: Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA 2016;315(13):1354-1361.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis

These investigators recruited mechanically ventilated adult patients who were ready for extubation and who met the criteria for low risk for reintubation. Low risk was defined as: younger than 65 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score of less than 12; fewer than 2 comorbidities; body mass index of less than 30; ability to manage secretions; simple weaning; and the absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency issues, and prolonged mechanical ventilation.

Using concealed allocation, these patients were randomized to receive either conventional oxygen therapy or high-flow oxygen therapy for 24 hours following extubation. Conventional oxygen therapy was continued in both groups after 24 hours as needed. The 2 groups had a mean age of 51 years and similar APACHE scores at baseline. The use of high-flow oxygen therapy reduced the rate of reintubation within 72 hours from 12.2% to 4.9% (absolute difference 7.2%; 95% CI 2.5%-12.2%; number needed to treat [NNT] = 14; P = .004). There were no significant differences detected in the 2 groups in secondary outcomes including time to reintubation or hospital length of stay. Notably, the study population had a high proportion of surgical and neurocritical patients, resulting in one-third of the reintubations occurring because of nonrespiratory causes such as repeat surgery or altered mental status. When the analysis was limited to only the respiratory-related intubations, the reduced risk of reintubation persisted in the high-flow oxygen group (1.5% vs 8.7%; NNT = 14; P = .001).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of high-flow oxygen therapy for 24 hours following extubation reduce the risk of reintubation in low-risk patients?

Bottom line: Using high-flow nasal cannula oxygen therapy for 24 hours following extubation of patients who are already at low risk of reintubation further reduces the risk of reintubation. You would need to treat 14 patients with high-flow therapy to prevent reintubation in one patient. (LOE = 1b)

Reference: Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA 2016;315(13):1354-1361.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis

These investigators recruited mechanically ventilated adult patients who were ready for extubation and who met the criteria for low risk for reintubation. Low risk was defined as: younger than 65 years; Acute Physiology and Chronic Health Evaluation (APACHE) II score of less than 12; fewer than 2 comorbidities; body mass index of less than 30; ability to manage secretions; simple weaning; and the absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency issues, and prolonged mechanical ventilation.

Using concealed allocation, these patients were randomized to receive either conventional oxygen therapy or high-flow oxygen therapy for 24 hours following extubation. Conventional oxygen therapy was continued in both groups after 24 hours as needed. The 2 groups had a mean age of 51 years and similar APACHE scores at baseline. The use of high-flow oxygen therapy reduced the rate of reintubation within 72 hours from 12.2% to 4.9% (absolute difference 7.2%; 95% CI 2.5%-12.2%; number needed to treat [NNT] = 14; P = .004). There were no significant differences detected in the 2 groups in secondary outcomes including time to reintubation or hospital length of stay. Notably, the study population had a high proportion of surgical and neurocritical patients, resulting in one-third of the reintubations occurring because of nonrespiratory causes such as repeat surgery or altered mental status. When the analysis was limited to only the respiratory-related intubations, the reduced risk of reintubation persisted in the high-flow oxygen group (1.5% vs 8.7%; NNT = 14; P = .001).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

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Offering palliative care early to hospitalized patients with multiple serious conditions could improve care and help reduce healthcare spending, according to “Palliative Care Teams’ Cost-Saving Effect Is Larger for Cancer Patients with Higher Numbers of Comorbidities,” published in Health Affairs. When adults with advanced cancer (excluding those with dementia) received a palliative care consultation within two days of admission, costs were 22% lower for patients with a comorbidity score of 2 to 3 and 32% lower for those with a score of 4 or higher.

Reference

1. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.

Quick Byte

Efforts to shift provider payment from fee-for-service to more risk-based alternatives are proceeding slowly: Nearly 95% of all 2013 physician office visits were reimbursed as fee-for-service.

Reference

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414. doi:10.1377/hlthaff.2015.1291.

Offering palliative care early to hospitalized patients with multiple serious conditions could improve care and help reduce healthcare spending, according to “Palliative Care Teams’ Cost-Saving Effect Is Larger for Cancer Patients with Higher Numbers of Comorbidities,” published in Health Affairs. When adults with advanced cancer (excluding those with dementia) received a palliative care consultation within two days of admission, costs were 22% lower for patients with a comorbidity score of 2 to 3 and 32% lower for those with a score of 4 or higher.

Reference

1. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.

Quick Byte

Efforts to shift provider payment from fee-for-service to more risk-based alternatives are proceeding slowly: Nearly 95% of all 2013 physician office visits were reimbursed as fee-for-service.

Reference

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414. doi:10.1377/hlthaff.2015.1291.

Offering palliative care early to hospitalized patients with multiple serious conditions could improve care and help reduce healthcare spending, according to “Palliative Care Teams’ Cost-Saving Effect Is Larger for Cancer Patients with Higher Numbers of Comorbidities,” published in Health Affairs. When adults with advanced cancer (excluding those with dementia) received a palliative care consultation within two days of admission, costs were 22% lower for patients with a comorbidity score of 2 to 3 and 32% lower for those with a score of 4 or higher.

Reference

1. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.

Quick Byte

Efforts to shift provider payment from fee-for-service to more risk-based alternatives are proceeding slowly: Nearly 95% of all 2013 physician office visits were reimbursed as fee-for-service.

Reference

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414. doi:10.1377/hlthaff.2015.1291.

Alert emails can be a simple, low-cost means of improving quality in a hospital, as the Department of Medicine at Massachusetts General Hospital in Boston learned. The trial there is summarized in “Alert Emails Improve Quality in a Large Academic Hospitalist Group,” an abstract by Warren Chuang, MD, and Bijay Acharya, MD.

When each of the hospital’s divisions was asked to designate important quality goals, the Hospital Medicine Division chose pre-noon discharge rate and discharge summary completion timeliness. Group emails were deployed first: Monthly alerts went to the entire unit emphasizing target numbers, reporting the group’s current performance, and outlining future performance needed to meet the targets. This led to an improvement in discharge summary completion rate from 89.1% to 94.8%.

The same improvement was not seen in the pre-noon discharge rate, so the next step was to send individual emails to every attending whose pre-noon discharge rate was below target levels. This resulted in dramatic improvement: Having fallen to 16.0%, the rate rose to 19.5% after the email campaign.

The authors’ conclusion? Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures.

Reference

1. Chuang W, Acharya B. Alert emails improve quality in a large academic hospitalist group [abstract]. J Hosp Med. 2015;10(suppl2). Available at: http://www.shmabstracts.com/abstract/alert-emails-improve-quality-in-a-large-academic-hospitalist-group/. Accessed February 14, 2016.

Alert emails can be a simple, low-cost means of improving quality in a hospital, as the Department of Medicine at Massachusetts General Hospital in Boston learned. The trial there is summarized in “Alert Emails Improve Quality in a Large Academic Hospitalist Group,” an abstract by Warren Chuang, MD, and Bijay Acharya, MD.

When each of the hospital’s divisions was asked to designate important quality goals, the Hospital Medicine Division chose pre-noon discharge rate and discharge summary completion timeliness. Group emails were deployed first: Monthly alerts went to the entire unit emphasizing target numbers, reporting the group’s current performance, and outlining future performance needed to meet the targets. This led to an improvement in discharge summary completion rate from 89.1% to 94.8%.

The same improvement was not seen in the pre-noon discharge rate, so the next step was to send individual emails to every attending whose pre-noon discharge rate was below target levels. This resulted in dramatic improvement: Having fallen to 16.0%, the rate rose to 19.5% after the email campaign.

The authors’ conclusion? Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures.

Reference

1. Chuang W, Acharya B. Alert emails improve quality in a large academic hospitalist group [abstract]. J Hosp Med. 2015;10(suppl2). Available at: http://www.shmabstracts.com/abstract/alert-emails-improve-quality-in-a-large-academic-hospitalist-group/. Accessed February 14, 2016.

Alert emails can be a simple, low-cost means of improving quality in a hospital, as the Department of Medicine at Massachusetts General Hospital in Boston learned. The trial there is summarized in “Alert Emails Improve Quality in a Large Academic Hospitalist Group,” an abstract by Warren Chuang, MD, and Bijay Acharya, MD.

When each of the hospital’s divisions was asked to designate important quality goals, the Hospital Medicine Division chose pre-noon discharge rate and discharge summary completion timeliness. Group emails were deployed first: Monthly alerts went to the entire unit emphasizing target numbers, reporting the group’s current performance, and outlining future performance needed to meet the targets. This led to an improvement in discharge summary completion rate from 89.1% to 94.8%.

The same improvement was not seen in the pre-noon discharge rate, so the next step was to send individual emails to every attending whose pre-noon discharge rate was below target levels. This resulted in dramatic improvement: Having fallen to 16.0%, the rate rose to 19.5% after the email campaign.

The authors’ conclusion? Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures.

Reference

1. Chuang W, Acharya B. Alert emails improve quality in a large academic hospitalist group [abstract]. J Hosp Med. 2015;10(suppl2). Available at: http://www.shmabstracts.com/abstract/alert-emails-improve-quality-in-a-large-academic-hospitalist-group/. Accessed February 14, 2016.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

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

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

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

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

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

Not much intimidates Jasen Gundersen, MD, president of the acute care services division at TeamHealth, an outsourcer of hospital-based clinical and specialty services based in Knoxville, Tenn. Besides traveling 150,000 miles a year overseeing 2,500 hospitalists at 285 facilities, Dr. Gundersen has climbed frozen waterfalls in Vermont and New Hampshire, raced in bicycle competitions, and skied mountains towering 10,000 feet.

But his love for adventure is now focused below the surface. Over the years, he has spent many weekends diving in open waters surrounding southeast Florida; Cozumel, Mexico; Turks and Caicos; and the Cayman Islands. He believes there’s no place on Earth that is as peaceful, serene, or even magical as under the ocean.

Reclaimed Passion

Growing up in Connecticut, Dr. Gundersen and his family frequently vacationed in the Bahamas, where he was introduced to scuba diving.

“As a teenager, I really loved diving,” he recalls. “Every time we went to the Bahamas, I always tried to go diving or snorkeling.”

However, the harsh Connecticut winters and frigid Atlantic Ocean prevented him from diving. More delays followed, namely medical school. After graduating from the University of Connecticut School of Medicine in 2000, Dr. Gundersen completed his three-year residency in family medicine at the UMass Memorial Medical Center. During the next two years, he worked as a physician and hospitalist at the Family Health Center of Worcester, a federally qualified health center where he did everything from examining sore throats to delivering babies.

In 2005, he launched a small hospital medicine program at the University of Massachusetts that quickly grew and bumped up his title to division chief for hospital medicine. Then in January 2011, he accepted a new position as chief medical officer at TeamHealth, requiring him and his wife, Elizabeth, also a hospitalist, to move to Florida.

Within several weeks, the couple started diving near their home in Pompano Beach. He says Elizabeth, his “diving buddy,” was eager to learn and developed a passion for scuba diving that rivals his own.

“We did 80 to 90 dives in the first year we were down there,” Dr. Gundersen says, explaining that unlike many sports, diving doesn’t require athletic ability, size, or strength. “We normally did recreational diving, where you basically can always swim slowly straight to the surface. You don’t stay down long enough that you build up enough bubbles in your system that you have to stop on the way up.”

Sharks and Shipwrecks

Since then, Dr. Gundersen purchased a 38-foot powerboat, became a PADI (Professional Association of Diving Instructors) open-water scuba instructor, and earned a U.S. Coast Guard 50-ton master captain’s license. He and Elizabeth are certified for advanced nitrox and decompression diving, technical diving that requires the use of different gases to decompress when heading to the surface, and diving in overhead environments, such as caves or shipwrecks.

“One of our favorite wrecks is called the USS Spiegel Gove that sits on the ocean floor in Key Largo,” he says, adding that on occasion, they also swim with hammerhead sharks. “The walls of the ship go 30 feet up on each side. You can swim where they loaded the cargo and see the old crane above you. It’s spectacular.”

Among their favorite spots to dive is Eagle Ray Pass in Grand Cayman, where entire schools of spotted eagle rays live, he says, adding that 17 rays swam and floated around them during one dive.

Fortunately, after some initial costs, he says the sport isn’t too expensive, roughly around $1,500 to get started. Basic scuba gear costs approximately $1,000. Likewise, certifications can run $350 a piece. Boat trips range between $60 and $100, unless you prefer shore diving, where you park at the beach and simply swim into the ocean. Then add a few extra dollars to fill your tank with air.

Scary and Serene

Although the Gundersens are accomplished divers who prefer warm waters and flat seas, Dr. Gundersen says only one moment of one dive actually scared him.

Years ago, he, Elizabeth, and a friend were wreck diving. Diving protocol is based on follow the leader, where divers swim into wrecks one at a time, follow each other, and signal their turns. Somehow, their friend unintentionally swam in between Dr. Gundersen and his wife. Elizabeth and the friend then turned to see something inside the wreck, but the friend failed to signal to Dr. Gundersen that they were turning.

“I went a bit farther and turned around,” Dr. Gundersen recalls. “He and Elizabeth were gone. It gave me a moment of panic. I’m particularly careful about staying with my diving buddy and making sure we don’t get lost. It wasn’t dangerous but broke the cardinal rule of what you’re supposed to do when diving. I swam back and found them.”

While that was a rare experience, he says diving, when done properly, is the most peaceful and serene activity that people may experience. When under water, all you hear are your air bubbles. There are no cellphones ringing, emails or texts to respond to, or work issues to resolve.

“Work-life balance is a really big deal for me and my team to prevent burnout,” Dr. Gundersen says. “It allows me to have my personal time to enjoy and relax so when I’m back at work on Monday, my batteries are recharged. I’m ready to go.” TH

Carol Patton is a freelance writer in Las Vegas.

Not much intimidates Jasen Gundersen, MD, president of the acute care services division at TeamHealth, an outsourcer of hospital-based clinical and specialty services based in Knoxville, Tenn. Besides traveling 150,000 miles a year overseeing 2,500 hospitalists at 285 facilities, Dr. Gundersen has climbed frozen waterfalls in Vermont and New Hampshire, raced in bicycle competitions, and skied mountains towering 10,000 feet.

But his love for adventure is now focused below the surface. Over the years, he has spent many weekends diving in open waters surrounding southeast Florida; Cozumel, Mexico; Turks and Caicos; and the Cayman Islands. He believes there’s no place on Earth that is as peaceful, serene, or even magical as under the ocean.

Reclaimed Passion

Growing up in Connecticut, Dr. Gundersen and his family frequently vacationed in the Bahamas, where he was introduced to scuba diving.

“As a teenager, I really loved diving,” he recalls. “Every time we went to the Bahamas, I always tried to go diving or snorkeling.”

However, the harsh Connecticut winters and frigid Atlantic Ocean prevented him from diving. More delays followed, namely medical school. After graduating from the University of Connecticut School of Medicine in 2000, Dr. Gundersen completed his three-year residency in family medicine at the UMass Memorial Medical Center. During the next two years, he worked as a physician and hospitalist at the Family Health Center of Worcester, a federally qualified health center where he did everything from examining sore throats to delivering babies.

In 2005, he launched a small hospital medicine program at the University of Massachusetts that quickly grew and bumped up his title to division chief for hospital medicine. Then in January 2011, he accepted a new position as chief medical officer at TeamHealth, requiring him and his wife, Elizabeth, also a hospitalist, to move to Florida.

Within several weeks, the couple started diving near their home in Pompano Beach. He says Elizabeth, his “diving buddy,” was eager to learn and developed a passion for scuba diving that rivals his own.

“We did 80 to 90 dives in the first year we were down there,” Dr. Gundersen says, explaining that unlike many sports, diving doesn’t require athletic ability, size, or strength. “We normally did recreational diving, where you basically can always swim slowly straight to the surface. You don’t stay down long enough that you build up enough bubbles in your system that you have to stop on the way up.”

Sharks and Shipwrecks

Since then, Dr. Gundersen purchased a 38-foot powerboat, became a PADI (Professional Association of Diving Instructors) open-water scuba instructor, and earned a U.S. Coast Guard 50-ton master captain’s license. He and Elizabeth are certified for advanced nitrox and decompression diving, technical diving that requires the use of different gases to decompress when heading to the surface, and diving in overhead environments, such as caves or shipwrecks.

“One of our favorite wrecks is called the USS Spiegel Gove that sits on the ocean floor in Key Largo,” he says, adding that on occasion, they also swim with hammerhead sharks. “The walls of the ship go 30 feet up on each side. You can swim where they loaded the cargo and see the old crane above you. It’s spectacular.”

Among their favorite spots to dive is Eagle Ray Pass in Grand Cayman, where entire schools of spotted eagle rays live, he says, adding that 17 rays swam and floated around them during one dive.

Fortunately, after some initial costs, he says the sport isn’t too expensive, roughly around $1,500 to get started. Basic scuba gear costs approximately $1,000. Likewise, certifications can run $350 a piece. Boat trips range between $60 and $100, unless you prefer shore diving, where you park at the beach and simply swim into the ocean. Then add a few extra dollars to fill your tank with air.

Scary and Serene

Although the Gundersens are accomplished divers who prefer warm waters and flat seas, Dr. Gundersen says only one moment of one dive actually scared him.

Years ago, he, Elizabeth, and a friend were wreck diving. Diving protocol is based on follow the leader, where divers swim into wrecks one at a time, follow each other, and signal their turns. Somehow, their friend unintentionally swam in between Dr. Gundersen and his wife. Elizabeth and the friend then turned to see something inside the wreck, but the friend failed to signal to Dr. Gundersen that they were turning.

“I went a bit farther and turned around,” Dr. Gundersen recalls. “He and Elizabeth were gone. It gave me a moment of panic. I’m particularly careful about staying with my diving buddy and making sure we don’t get lost. It wasn’t dangerous but broke the cardinal rule of what you’re supposed to do when diving. I swam back and found them.”

While that was a rare experience, he says diving, when done properly, is the most peaceful and serene activity that people may experience. When under water, all you hear are your air bubbles. There are no cellphones ringing, emails or texts to respond to, or work issues to resolve.

“Work-life balance is a really big deal for me and my team to prevent burnout,” Dr. Gundersen says. “It allows me to have my personal time to enjoy and relax so when I’m back at work on Monday, my batteries are recharged. I’m ready to go.” TH

Carol Patton is a freelance writer in Las Vegas.

Not much intimidates Jasen Gundersen, MD, president of the acute care services division at TeamHealth, an outsourcer of hospital-based clinical and specialty services based in Knoxville, Tenn. Besides traveling 150,000 miles a year overseeing 2,500 hospitalists at 285 facilities, Dr. Gundersen has climbed frozen waterfalls in Vermont and New Hampshire, raced in bicycle competitions, and skied mountains towering 10,000 feet.

But his love for adventure is now focused below the surface. Over the years, he has spent many weekends diving in open waters surrounding southeast Florida; Cozumel, Mexico; Turks and Caicos; and the Cayman Islands. He believes there’s no place on Earth that is as peaceful, serene, or even magical as under the ocean.

Reclaimed Passion

Growing up in Connecticut, Dr. Gundersen and his family frequently vacationed in the Bahamas, where he was introduced to scuba diving.

“As a teenager, I really loved diving,” he recalls. “Every time we went to the Bahamas, I always tried to go diving or snorkeling.”

However, the harsh Connecticut winters and frigid Atlantic Ocean prevented him from diving. More delays followed, namely medical school. After graduating from the University of Connecticut School of Medicine in 2000, Dr. Gundersen completed his three-year residency in family medicine at the UMass Memorial Medical Center. During the next two years, he worked as a physician and hospitalist at the Family Health Center of Worcester, a federally qualified health center where he did everything from examining sore throats to delivering babies.

In 2005, he launched a small hospital medicine program at the University of Massachusetts that quickly grew and bumped up his title to division chief for hospital medicine. Then in January 2011, he accepted a new position as chief medical officer at TeamHealth, requiring him and his wife, Elizabeth, also a hospitalist, to move to Florida.

Within several weeks, the couple started diving near their home in Pompano Beach. He says Elizabeth, his “diving buddy,” was eager to learn and developed a passion for scuba diving that rivals his own.

“We did 80 to 90 dives in the first year we were down there,” Dr. Gundersen says, explaining that unlike many sports, diving doesn’t require athletic ability, size, or strength. “We normally did recreational diving, where you basically can always swim slowly straight to the surface. You don’t stay down long enough that you build up enough bubbles in your system that you have to stop on the way up.”

Sharks and Shipwrecks

Since then, Dr. Gundersen purchased a 38-foot powerboat, became a PADI (Professional Association of Diving Instructors) open-water scuba instructor, and earned a U.S. Coast Guard 50-ton master captain’s license. He and Elizabeth are certified for advanced nitrox and decompression diving, technical diving that requires the use of different gases to decompress when heading to the surface, and diving in overhead environments, such as caves or shipwrecks.

“One of our favorite wrecks is called the USS Spiegel Gove that sits on the ocean floor in Key Largo,” he says, adding that on occasion, they also swim with hammerhead sharks. “The walls of the ship go 30 feet up on each side. You can swim where they loaded the cargo and see the old crane above you. It’s spectacular.”

Among their favorite spots to dive is Eagle Ray Pass in Grand Cayman, where entire schools of spotted eagle rays live, he says, adding that 17 rays swam and floated around them during one dive.

Fortunately, after some initial costs, he says the sport isn’t too expensive, roughly around $1,500 to get started. Basic scuba gear costs approximately $1,000. Likewise, certifications can run $350 a piece. Boat trips range between $60 and $100, unless you prefer shore diving, where you park at the beach and simply swim into the ocean. Then add a few extra dollars to fill your tank with air.

Scary and Serene

Although the Gundersens are accomplished divers who prefer warm waters and flat seas, Dr. Gundersen says only one moment of one dive actually scared him.

Years ago, he, Elizabeth, and a friend were wreck diving. Diving protocol is based on follow the leader, where divers swim into wrecks one at a time, follow each other, and signal their turns. Somehow, their friend unintentionally swam in between Dr. Gundersen and his wife. Elizabeth and the friend then turned to see something inside the wreck, but the friend failed to signal to Dr. Gundersen that they were turning.

“I went a bit farther and turned around,” Dr. Gundersen recalls. “He and Elizabeth were gone. It gave me a moment of panic. I’m particularly careful about staying with my diving buddy and making sure we don’t get lost. It wasn’t dangerous but broke the cardinal rule of what you’re supposed to do when diving. I swam back and found them.”

While that was a rare experience, he says diving, when done properly, is the most peaceful and serene activity that people may experience. When under water, all you hear are your air bubbles. There are no cellphones ringing, emails or texts to respond to, or work issues to resolve.

“Work-life balance is a really big deal for me and my team to prevent burnout,” Dr. Gundersen says. “It allows me to have my personal time to enjoy and relax so when I’m back at work on Monday, my batteries are recharged. I’m ready to go.” TH

Carol Patton is a freelance writer in Las Vegas.

To promote achievable solutions in the ongoing debate on drug financing, Anthem, Inc. and Eli Lilly and Company are offering two policy proposals, which are detailed in “Discovering New Medicines and New Ways to Pay for Them,” published on the Health Affairs blog.

The first proposal calls for clarifying federal regulation to reduce perceived barriers impeding conversations between health benefit companies and biopharmaceutical companies about drugs prior to the drugs being approved for sale.

The second proposal calls for changes to federal laws and regulations to mitigate the barriers that make it difficult to move toward value-based contracting.

“A change in policies could open the door to new opportunities for hospitalists and their employers to create more high-value care,” says Sam Nussbaum, MD, Anthem clinical advisor. “Today, hospitals are paid for seeing patients. What if hospitals participated in a value-based arrangement with manufacturers and insurers that included treating patients with a specific condition with a new therapy proven to be more effective in producing better health outcomes, including keeping patients out of the hospital?”

Reference

1. Nussbaum S, Ricks D. Discovering new medicines and new ways to pay for them. Health Policy Lab. Available at: http://healthaffairs.org/blog/2016/01/29/discovering-new-medicines-and-new-ways-to-pay-for-them/. Accessed February 15, 2016.

To promote achievable solutions in the ongoing debate on drug financing, Anthem, Inc. and Eli Lilly and Company are offering two policy proposals, which are detailed in “Discovering New Medicines and New Ways to Pay for Them,” published on the Health Affairs blog.

The first proposal calls for clarifying federal regulation to reduce perceived barriers impeding conversations between health benefit companies and biopharmaceutical companies about drugs prior to the drugs being approved for sale.

The second proposal calls for changes to federal laws and regulations to mitigate the barriers that make it difficult to move toward value-based contracting.

“A change in policies could open the door to new opportunities for hospitalists and their employers to create more high-value care,” says Sam Nussbaum, MD, Anthem clinical advisor. “Today, hospitals are paid for seeing patients. What if hospitals participated in a value-based arrangement with manufacturers and insurers that included treating patients with a specific condition with a new therapy proven to be more effective in producing better health outcomes, including keeping patients out of the hospital?”

Reference

1. Nussbaum S, Ricks D. Discovering new medicines and new ways to pay for them. Health Policy Lab. Available at: http://healthaffairs.org/blog/2016/01/29/discovering-new-medicines-and-new-ways-to-pay-for-them/. Accessed February 15, 2016.

To promote achievable solutions in the ongoing debate on drug financing, Anthem, Inc. and Eli Lilly and Company are offering two policy proposals, which are detailed in “Discovering New Medicines and New Ways to Pay for Them,” published on the Health Affairs blog.

The first proposal calls for clarifying federal regulation to reduce perceived barriers impeding conversations between health benefit companies and biopharmaceutical companies about drugs prior to the drugs being approved for sale.

The second proposal calls for changes to federal laws and regulations to mitigate the barriers that make it difficult to move toward value-based contracting.

“A change in policies could open the door to new opportunities for hospitalists and their employers to create more high-value care,” says Sam Nussbaum, MD, Anthem clinical advisor. “Today, hospitals are paid for seeing patients. What if hospitals participated in a value-based arrangement with manufacturers and insurers that included treating patients with a specific condition with a new therapy proven to be more effective in producing better health outcomes, including keeping patients out of the hospital?”

Reference

1. Nussbaum S, Ricks D. Discovering new medicines and new ways to pay for them. Health Policy Lab. Available at: http://healthaffairs.org/blog/2016/01/29/discovering-new-medicines-and-new-ways-to-pay-for-them/. Accessed February 15, 2016.

Procedures are the most expensive item in healthcare, but tremendous variation remains in quality.

“In part that’ s because we have weak systems of peer support and in part because medicine sanctions a physician to do procedures, and then for the next 40 or 50 years, a surgeon can receive no input and not change their technique even though the field changes,” says Martin Makary, MD, MPH, professor of surgery and health policy and management at Johns Hopkins University in Baltimore.

Video could be used to address this, he suggests in an editorial called “Video Transparency: A Powerful Tool for Patient Safety and Quality Improvement” in the January 2016 BMJ Quality & Safety.

“In areas of excellence outside of medicine—football, aviation—they use video and video feedback for educational purposes. In healthcare, we can also use video to learn,” he says. “In surgical care, we can actually predict outcomes based on independent review of procedure video, but we just choose not to record videos because we don’ t have the infrastructure set up to provide feedback.”

When it has been done, he says, it’ s been received with enthusiasm. This doesn’ t mean cameras in primary-care clinics monitoring physicians.

“We’ re talking about the video-based procedures being recorded, not being erased with the next procedure that’ s done,” he says. “In the past, we couldn’ t do this with videotapes, but now with the capacity of memory and video data storage, there’ s an opportunity to leave the ‘ record’ button on on the video-based procedures that are already taking place.”

Reference

1. Joo S, Xu T, Makary MA. Video transparency: a powerful tool for patient safety and quality improvement [published online ahead of print January 12, 2016]. BMJ Qual Saf,doi:10.1136/bmjqs-2015-005058.

Procedures are the most expensive item in healthcare, but tremendous variation remains in quality.

“In part that’ s because we have weak systems of peer support and in part because medicine sanctions a physician to do procedures, and then for the next 40 or 50 years, a surgeon can receive no input and not change their technique even though the field changes,” says Martin Makary, MD, MPH, professor of surgery and health policy and management at Johns Hopkins University in Baltimore.

Video could be used to address this, he suggests in an editorial called “Video Transparency: A Powerful Tool for Patient Safety and Quality Improvement” in the January 2016 BMJ Quality & Safety.

“In areas of excellence outside of medicine—football, aviation—they use video and video feedback for educational purposes. In healthcare, we can also use video to learn,” he says. “In surgical care, we can actually predict outcomes based on independent review of procedure video, but we just choose not to record videos because we don’ t have the infrastructure set up to provide feedback.”

When it has been done, he says, it’ s been received with enthusiasm. This doesn’ t mean cameras in primary-care clinics monitoring physicians.

“We’ re talking about the video-based procedures being recorded, not being erased with the next procedure that’ s done,” he says. “In the past, we couldn’ t do this with videotapes, but now with the capacity of memory and video data storage, there’ s an opportunity to leave the ‘ record’ button on on the video-based procedures that are already taking place.”

Reference

1. Joo S, Xu T, Makary MA. Video transparency: a powerful tool for patient safety and quality improvement [published online ahead of print January 12, 2016]. BMJ Qual Saf,doi:10.1136/bmjqs-2015-005058.

Procedures are the most expensive item in healthcare, but tremendous variation remains in quality.

“In part that’ s because we have weak systems of peer support and in part because medicine sanctions a physician to do procedures, and then for the next 40 or 50 years, a surgeon can receive no input and not change their technique even though the field changes,” says Martin Makary, MD, MPH, professor of surgery and health policy and management at Johns Hopkins University in Baltimore.

Video could be used to address this, he suggests in an editorial called “Video Transparency: A Powerful Tool for Patient Safety and Quality Improvement” in the January 2016 BMJ Quality & Safety.

“In areas of excellence outside of medicine—football, aviation—they use video and video feedback for educational purposes. In healthcare, we can also use video to learn,” he says. “In surgical care, we can actually predict outcomes based on independent review of procedure video, but we just choose not to record videos because we don’ t have the infrastructure set up to provide feedback.”

When it has been done, he says, it’ s been received with enthusiasm. This doesn’ t mean cameras in primary-care clinics monitoring physicians.

“We’ re talking about the video-based procedures being recorded, not being erased with the next procedure that’ s done,” he says. “In the past, we couldn’ t do this with videotapes, but now with the capacity of memory and video data storage, there’ s an opportunity to leave the ‘ record’ button on on the video-based procedures that are already taking place.”

Reference

1. Joo S, Xu T, Makary MA. Video transparency: a powerful tool for patient safety and quality improvement [published online ahead of print January 12, 2016]. BMJ Qual Saf,doi:10.1136/bmjqs-2015-005058.