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Dr. Hospitalist: HM Groups Must Adapt to New Career Landscape
Dear Dr. Hospitalist:
Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?
Missing My Friends in the Midwest
Dr. Hospitalist responds:
Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.
One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.
Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.
Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).
While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.
Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.
I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH
Dear Dr. Hospitalist:
Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?
Missing My Friends in the Midwest
Dr. Hospitalist responds:
Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.
One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.
Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.
Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).
While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.
Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.
I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH
Dear Dr. Hospitalist:
Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?
Missing My Friends in the Midwest
Dr. Hospitalist responds:
Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.
One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.
Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.
Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).
While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.
Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.
I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH
Displaying Prices to Providers May Reduce Overall Ordering Costs
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Prophylaxis and Treatment of Venous Thromboembolism in Cancer Patients
The Case
A 62-year-old woman with a past medical history significant for metastatic adenocarcinoma of the lung presents to the ED with complaints of fever and shortness of breath. She has recently completed her first cycle of carboplatin, pemetrexed, and bevacizumab. Upon admission, she is found to have an absolute neutrophil count of 800 and a platelet count of 48,000. She is admitted for neutropenic fever and placed on IV antimicrobials. Sequential compression devices are initiated for DVT prophylaxis.
Key Clinical Questions
What risk do cancer patients have for VTE?
Patients with cancer have a risk of clinically significant VTE that is four to seven times that of patients without malignancy.1 This is due to a number of reasons:
- Tumor cells produce procoagulant activity inducing thrombin formation;2
- The cancer itself can compress or invade deep veins; and3
- Some cancer therapies such L-asparaginase and thalidomide/lenalidomide, plus high-dose steroids, or anti-estrogen medications such as tamoxifen can also increase patients’ risk of VTE.3,4,5
What inpatients with cancer need VTE prophylaxis?
Much like other hospitalized medical patients, patients with cancer who have reduced mobility and are not on therapeutic anticoagulation should receive pharmacologic prophylaxis unless there is a contraindication.3,6,7,8 Cancer patients with acute medical illnesses should also likely receive prophylaxis if there are no contraindications, because the vast majority of these have factors increasing their VTE risk, including infection, kidney disease, or pulmonary disease.3,6,7,8 Patients undergoing major cancer surgery should also receive pharmacologic prophylaxis prior to surgery and for at least seven to 10 days post-operatively.3,6,7,8
For ambulatory cancer patients who are admitted for short courses of chemotherapy or for minor procedures, however, there is not enough evidence to recommend routine VTE prophylaxis.6,7 An exception to this is patients with multiple myeloma receiving thalidomide-based or lenalidomide-based chemotherapy, who should receive pharmacologic prophylaxis.6,7
What are the options available for VTE in hospitalized cancer patients?
The guidelines for VTE prophylaxis in hospitalized cancer patients recommend either unfractionated heparin (UFH) or low molecular weight heparin (LMWH) for prophylaxis when no contraindications exist.5 The only two LMWH that have been FDA approved for prophylaxis are enoxaparin and dalteparin. When deciding between UFH and LMWH, no evidence shows that one is better than the other in preventing VTE in hospitalized cancer patients.9 There is evidence that the use of LMWH results in a lower incidence of major hemorrhage when compared to UFH.10
What are the contraindications to pharmacologic VTE prophylaxis in cancer patients?
Contraindications for pharmacologic VTE prophylaxis in cancer patients include active major bleeding, thrombocytopenia (platelet count <50,000/µL), severe coagulopathy, inherited bleeding disorder, and at the time of surgery or invasive procedures (including lumbar puncture and epidural or spinal anesthesia).3,6,7 Those with contraindications to pharmacologic VTE prophylaxis should have mechanical prophylaxis instead.
What is the recommended treatment of VTE in cancer patients?
After the diagnosis of pulmonary embolism (PE) or DVT is found, LMWH is the preferred initial anticoagulant instead of UFH unless the patient has severe renal impairment (CrCl of less than 30 ml/min).6,7,8 LMWH is also preferred over warfarin for long-term anticoagulation during the initial six months of therapy.6,7,8 Following the initial six months, continued anticoagulation with either LMWH or warfarin could be considered in patients with active cancer, metastatic disease, or ongoing chemotherapy.6,7,8
When should IVC filters be considered in treating VTE in cancer patients?
IVC filter insertion should be reserved for those patients found to have a DVT or PE who have a contraindication to pharmacologic anticoagulation.3,6 It can be considered in patients who have recurrent VTE despite the appropriate use of optimally dosed LMWH therapy.6,8
What about the new oral anticoagulants?
At this point, because the majority of the major trials looking at the new oral anticoagulants (dabigatran, rivaroxaban, and apixaban) excluded cancer patients or included them only in small numbers, there is not enough evidence to support their use in cancer patients diagnosed with VTE.6,7,8
Back to the Case
On hospital day three, the patient is clinically improved. She is afebrile, her neutropenia has resolved, and her platelet count is up to 80,000. Her only complaint is pain and swelling of her left leg. A lower extremity Doppler is performed. She is found to have an acute left femoral DVT. The patient is then started on enoxaparin 1 mg/kg every 12 hours. Her left leg swelling and pain begin to improve, and she is discharged on enoxaparin and follows up with her oncologist in the next week. TH
Drs. Bell and O’Rourke are assistant professor of medicine in the division of hospital medicine at the University of California San Diego.
References
1. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood. 2013;122(10):1712-1723.
2. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293(6):715-722.
3. Streiff MB, Bockenstedt PL, Cataland SR, et al. Venous thromboembolic disease. J Natl Compr Canc Netw. 2013;11(11):1402-1429.
4. Payne JH, Vora AJ. Thrombosis and acute lymphoblastic leukaemia. Br J Haematol. 2007;138(4):430-445.
5. Amir E, Seruga B, Niraula S, Carlsson L, Ocaña A. Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst. 2011;103(17):1299-1309.
6. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189-2204.
7. Lyman GH, Bohlke K, Khorana AA, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. J Clin Oncol. 2015;33(6):654-656.
8. Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost. 2013;11(1):56-70.
9. Khorana AA. The NCCN clinical practice guidelines on venous thromboembolic disease: strategies for improving VTE prophylaxis in hospitalized cancer patients. Oncologist. 2007;12(11):1361-1370.
10. Mismetti P, Laporte-Simitisidis S, Tardy B, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomized clinical trials. Thromb Haemost. 2000;83(1):14-19.
The Case
A 62-year-old woman with a past medical history significant for metastatic adenocarcinoma of the lung presents to the ED with complaints of fever and shortness of breath. She has recently completed her first cycle of carboplatin, pemetrexed, and bevacizumab. Upon admission, she is found to have an absolute neutrophil count of 800 and a platelet count of 48,000. She is admitted for neutropenic fever and placed on IV antimicrobials. Sequential compression devices are initiated for DVT prophylaxis.
Key Clinical Questions
What risk do cancer patients have for VTE?
Patients with cancer have a risk of clinically significant VTE that is four to seven times that of patients without malignancy.1 This is due to a number of reasons:
- Tumor cells produce procoagulant activity inducing thrombin formation;2
- The cancer itself can compress or invade deep veins; and3
- Some cancer therapies such L-asparaginase and thalidomide/lenalidomide, plus high-dose steroids, or anti-estrogen medications such as tamoxifen can also increase patients’ risk of VTE.3,4,5
What inpatients with cancer need VTE prophylaxis?
Much like other hospitalized medical patients, patients with cancer who have reduced mobility and are not on therapeutic anticoagulation should receive pharmacologic prophylaxis unless there is a contraindication.3,6,7,8 Cancer patients with acute medical illnesses should also likely receive prophylaxis if there are no contraindications, because the vast majority of these have factors increasing their VTE risk, including infection, kidney disease, or pulmonary disease.3,6,7,8 Patients undergoing major cancer surgery should also receive pharmacologic prophylaxis prior to surgery and for at least seven to 10 days post-operatively.3,6,7,8
For ambulatory cancer patients who are admitted for short courses of chemotherapy or for minor procedures, however, there is not enough evidence to recommend routine VTE prophylaxis.6,7 An exception to this is patients with multiple myeloma receiving thalidomide-based or lenalidomide-based chemotherapy, who should receive pharmacologic prophylaxis.6,7
What are the options available for VTE in hospitalized cancer patients?
The guidelines for VTE prophylaxis in hospitalized cancer patients recommend either unfractionated heparin (UFH) or low molecular weight heparin (LMWH) for prophylaxis when no contraindications exist.5 The only two LMWH that have been FDA approved for prophylaxis are enoxaparin and dalteparin. When deciding between UFH and LMWH, no evidence shows that one is better than the other in preventing VTE in hospitalized cancer patients.9 There is evidence that the use of LMWH results in a lower incidence of major hemorrhage when compared to UFH.10
What are the contraindications to pharmacologic VTE prophylaxis in cancer patients?
Contraindications for pharmacologic VTE prophylaxis in cancer patients include active major bleeding, thrombocytopenia (platelet count <50,000/µL), severe coagulopathy, inherited bleeding disorder, and at the time of surgery or invasive procedures (including lumbar puncture and epidural or spinal anesthesia).3,6,7 Those with contraindications to pharmacologic VTE prophylaxis should have mechanical prophylaxis instead.
What is the recommended treatment of VTE in cancer patients?
After the diagnosis of pulmonary embolism (PE) or DVT is found, LMWH is the preferred initial anticoagulant instead of UFH unless the patient has severe renal impairment (CrCl of less than 30 ml/min).6,7,8 LMWH is also preferred over warfarin for long-term anticoagulation during the initial six months of therapy.6,7,8 Following the initial six months, continued anticoagulation with either LMWH or warfarin could be considered in patients with active cancer, metastatic disease, or ongoing chemotherapy.6,7,8
When should IVC filters be considered in treating VTE in cancer patients?
IVC filter insertion should be reserved for those patients found to have a DVT or PE who have a contraindication to pharmacologic anticoagulation.3,6 It can be considered in patients who have recurrent VTE despite the appropriate use of optimally dosed LMWH therapy.6,8
What about the new oral anticoagulants?
At this point, because the majority of the major trials looking at the new oral anticoagulants (dabigatran, rivaroxaban, and apixaban) excluded cancer patients or included them only in small numbers, there is not enough evidence to support their use in cancer patients diagnosed with VTE.6,7,8
Back to the Case
On hospital day three, the patient is clinically improved. She is afebrile, her neutropenia has resolved, and her platelet count is up to 80,000. Her only complaint is pain and swelling of her left leg. A lower extremity Doppler is performed. She is found to have an acute left femoral DVT. The patient is then started on enoxaparin 1 mg/kg every 12 hours. Her left leg swelling and pain begin to improve, and she is discharged on enoxaparin and follows up with her oncologist in the next week. TH
Drs. Bell and O’Rourke are assistant professor of medicine in the division of hospital medicine at the University of California San Diego.
References
1. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood. 2013;122(10):1712-1723.
2. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293(6):715-722.
3. Streiff MB, Bockenstedt PL, Cataland SR, et al. Venous thromboembolic disease. J Natl Compr Canc Netw. 2013;11(11):1402-1429.
4. Payne JH, Vora AJ. Thrombosis and acute lymphoblastic leukaemia. Br J Haematol. 2007;138(4):430-445.
5. Amir E, Seruga B, Niraula S, Carlsson L, Ocaña A. Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst. 2011;103(17):1299-1309.
6. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189-2204.
7. Lyman GH, Bohlke K, Khorana AA, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. J Clin Oncol. 2015;33(6):654-656.
8. Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost. 2013;11(1):56-70.
9. Khorana AA. The NCCN clinical practice guidelines on venous thromboembolic disease: strategies for improving VTE prophylaxis in hospitalized cancer patients. Oncologist. 2007;12(11):1361-1370.
10. Mismetti P, Laporte-Simitisidis S, Tardy B, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomized clinical trials. Thromb Haemost. 2000;83(1):14-19.
The Case
A 62-year-old woman with a past medical history significant for metastatic adenocarcinoma of the lung presents to the ED with complaints of fever and shortness of breath. She has recently completed her first cycle of carboplatin, pemetrexed, and bevacizumab. Upon admission, she is found to have an absolute neutrophil count of 800 and a platelet count of 48,000. She is admitted for neutropenic fever and placed on IV antimicrobials. Sequential compression devices are initiated for DVT prophylaxis.
Key Clinical Questions
What risk do cancer patients have for VTE?
Patients with cancer have a risk of clinically significant VTE that is four to seven times that of patients without malignancy.1 This is due to a number of reasons:
- Tumor cells produce procoagulant activity inducing thrombin formation;2
- The cancer itself can compress or invade deep veins; and3
- Some cancer therapies such L-asparaginase and thalidomide/lenalidomide, plus high-dose steroids, or anti-estrogen medications such as tamoxifen can also increase patients’ risk of VTE.3,4,5
What inpatients with cancer need VTE prophylaxis?
Much like other hospitalized medical patients, patients with cancer who have reduced mobility and are not on therapeutic anticoagulation should receive pharmacologic prophylaxis unless there is a contraindication.3,6,7,8 Cancer patients with acute medical illnesses should also likely receive prophylaxis if there are no contraindications, because the vast majority of these have factors increasing their VTE risk, including infection, kidney disease, or pulmonary disease.3,6,7,8 Patients undergoing major cancer surgery should also receive pharmacologic prophylaxis prior to surgery and for at least seven to 10 days post-operatively.3,6,7,8
For ambulatory cancer patients who are admitted for short courses of chemotherapy or for minor procedures, however, there is not enough evidence to recommend routine VTE prophylaxis.6,7 An exception to this is patients with multiple myeloma receiving thalidomide-based or lenalidomide-based chemotherapy, who should receive pharmacologic prophylaxis.6,7
What are the options available for VTE in hospitalized cancer patients?
The guidelines for VTE prophylaxis in hospitalized cancer patients recommend either unfractionated heparin (UFH) or low molecular weight heparin (LMWH) for prophylaxis when no contraindications exist.5 The only two LMWH that have been FDA approved for prophylaxis are enoxaparin and dalteparin. When deciding between UFH and LMWH, no evidence shows that one is better than the other in preventing VTE in hospitalized cancer patients.9 There is evidence that the use of LMWH results in a lower incidence of major hemorrhage when compared to UFH.10
What are the contraindications to pharmacologic VTE prophylaxis in cancer patients?
Contraindications for pharmacologic VTE prophylaxis in cancer patients include active major bleeding, thrombocytopenia (platelet count <50,000/µL), severe coagulopathy, inherited bleeding disorder, and at the time of surgery or invasive procedures (including lumbar puncture and epidural or spinal anesthesia).3,6,7 Those with contraindications to pharmacologic VTE prophylaxis should have mechanical prophylaxis instead.
What is the recommended treatment of VTE in cancer patients?
After the diagnosis of pulmonary embolism (PE) or DVT is found, LMWH is the preferred initial anticoagulant instead of UFH unless the patient has severe renal impairment (CrCl of less than 30 ml/min).6,7,8 LMWH is also preferred over warfarin for long-term anticoagulation during the initial six months of therapy.6,7,8 Following the initial six months, continued anticoagulation with either LMWH or warfarin could be considered in patients with active cancer, metastatic disease, or ongoing chemotherapy.6,7,8
When should IVC filters be considered in treating VTE in cancer patients?
IVC filter insertion should be reserved for those patients found to have a DVT or PE who have a contraindication to pharmacologic anticoagulation.3,6 It can be considered in patients who have recurrent VTE despite the appropriate use of optimally dosed LMWH therapy.6,8
What about the new oral anticoagulants?
At this point, because the majority of the major trials looking at the new oral anticoagulants (dabigatran, rivaroxaban, and apixaban) excluded cancer patients or included them only in small numbers, there is not enough evidence to support their use in cancer patients diagnosed with VTE.6,7,8
Back to the Case
On hospital day three, the patient is clinically improved. She is afebrile, her neutropenia has resolved, and her platelet count is up to 80,000. Her only complaint is pain and swelling of her left leg. A lower extremity Doppler is performed. She is found to have an acute left femoral DVT. The patient is then started on enoxaparin 1 mg/kg every 12 hours. Her left leg swelling and pain begin to improve, and she is discharged on enoxaparin and follows up with her oncologist in the next week. TH
Drs. Bell and O’Rourke are assistant professor of medicine in the division of hospital medicine at the University of California San Diego.
References
1. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood. 2013;122(10):1712-1723.
2. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293(6):715-722.
3. Streiff MB, Bockenstedt PL, Cataland SR, et al. Venous thromboembolic disease. J Natl Compr Canc Netw. 2013;11(11):1402-1429.
4. Payne JH, Vora AJ. Thrombosis and acute lymphoblastic leukaemia. Br J Haematol. 2007;138(4):430-445.
5. Amir E, Seruga B, Niraula S, Carlsson L, Ocaña A. Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst. 2011;103(17):1299-1309.
6. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189-2204.
7. Lyman GH, Bohlke K, Khorana AA, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. J Clin Oncol. 2015;33(6):654-656.
8. Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost. 2013;11(1):56-70.
9. Khorana AA. The NCCN clinical practice guidelines on venous thromboembolic disease: strategies for improving VTE prophylaxis in hospitalized cancer patients. Oncologist. 2007;12(11):1361-1370.
10. Mismetti P, Laporte-Simitisidis S, Tardy B, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomized clinical trials. Thromb Haemost. 2000;83(1):14-19.
Early Invasive Strategy for Acute Coronary Syndrome May, or May Not, Improve Outcomes
Clinical question: Does an early invasive strategy for acute coronary syndrome improve short-term outcomes?
Bottom line: According to this real-world observational study, an early invasive strategy—coronary angiogram within 72 hours of presentation—is associated with lower risks of short-term cardiac death and rehospitalization for myocardial infarction (MI). However, this inference may not be valid because of a lack of key clinical information that may have influenced the data. (LOE = 2b-)
Reference: Hansen KW, Sorensen R, Madsen M, et al. Effectiveness of an early versus a conservative invasive treatment strategy in acute coronary syndromes. Ann Intern Med. 2015;163(10):737-746.
Study design: Cohort (retrospective)
Funding source: Foundation
Allocation: Uncertain
Setting: Inpatient (any location) with outpatient follow-up
Synopsis: Using data from a Danish national registry, these investigators included patients aged 30 years to 90 years who were hospitalized with a first episode of unstable angina or acute MI. Patients were identified as having had an early invasive strategy (diagnostic coronary angiogram within 72 hours of hospitalization) or a conservative invasive strategy (coronary angiogram after 72 hours or no angiogram). The primary outcome was cardiac death or rehospitalization for MI within 60 days.
The investigators used propensity score matching to balance the baseline characteristics of the 2 groups in the initial cohort of 54,000 patients, resulting in 9852 matched patient-pairs. Notably, 42% of the conservative-strategy patients in the propensity-matched cohort received no cardiac catheterization. Overall, treatment with an early invasive strategy was associated with lower risks of cardiac death (5.9% vs 7.6%; number needed to treat [NNT] = 59; P < .001), all-cause death (7.3% vs 10.6%; NNT = 30; P < .001), and rehospitalization for MI (3.4% vs 5%; NNT = 63; P < .001).
However, as an accompanying editorial suggests, the causal inference is not necessarily valid. Given the use of an administrative database, the investigators lacked important clinical information, including indications for the angiograms performed, troponin levels, ejection fractions, and electrocardiogram findings. Without these key data, it is difficult to say whether they were comparing apples to apples, even after propensity score matching. Additionally, the study really just measures the timing of the initial angiogram without taking into account procedures done later that may have affected outcomes. As such, the validity of this study is questionable and, although the results agree with previous randomized clinical trial outcomes, it neither strengthens nor weakens what is already known.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Does an early invasive strategy for acute coronary syndrome improve short-term outcomes?
Bottom line: According to this real-world observational study, an early invasive strategy—coronary angiogram within 72 hours of presentation—is associated with lower risks of short-term cardiac death and rehospitalization for myocardial infarction (MI). However, this inference may not be valid because of a lack of key clinical information that may have influenced the data. (LOE = 2b-)
Reference: Hansen KW, Sorensen R, Madsen M, et al. Effectiveness of an early versus a conservative invasive treatment strategy in acute coronary syndromes. Ann Intern Med. 2015;163(10):737-746.
Study design: Cohort (retrospective)
Funding source: Foundation
Allocation: Uncertain
Setting: Inpatient (any location) with outpatient follow-up
Synopsis: Using data from a Danish national registry, these investigators included patients aged 30 years to 90 years who were hospitalized with a first episode of unstable angina or acute MI. Patients were identified as having had an early invasive strategy (diagnostic coronary angiogram within 72 hours of hospitalization) or a conservative invasive strategy (coronary angiogram after 72 hours or no angiogram). The primary outcome was cardiac death or rehospitalization for MI within 60 days.
The investigators used propensity score matching to balance the baseline characteristics of the 2 groups in the initial cohort of 54,000 patients, resulting in 9852 matched patient-pairs. Notably, 42% of the conservative-strategy patients in the propensity-matched cohort received no cardiac catheterization. Overall, treatment with an early invasive strategy was associated with lower risks of cardiac death (5.9% vs 7.6%; number needed to treat [NNT] = 59; P < .001), all-cause death (7.3% vs 10.6%; NNT = 30; P < .001), and rehospitalization for MI (3.4% vs 5%; NNT = 63; P < .001).
However, as an accompanying editorial suggests, the causal inference is not necessarily valid. Given the use of an administrative database, the investigators lacked important clinical information, including indications for the angiograms performed, troponin levels, ejection fractions, and electrocardiogram findings. Without these key data, it is difficult to say whether they were comparing apples to apples, even after propensity score matching. Additionally, the study really just measures the timing of the initial angiogram without taking into account procedures done later that may have affected outcomes. As such, the validity of this study is questionable and, although the results agree with previous randomized clinical trial outcomes, it neither strengthens nor weakens what is already known.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Does an early invasive strategy for acute coronary syndrome improve short-term outcomes?
Bottom line: According to this real-world observational study, an early invasive strategy—coronary angiogram within 72 hours of presentation—is associated with lower risks of short-term cardiac death and rehospitalization for myocardial infarction (MI). However, this inference may not be valid because of a lack of key clinical information that may have influenced the data. (LOE = 2b-)
Reference: Hansen KW, Sorensen R, Madsen M, et al. Effectiveness of an early versus a conservative invasive treatment strategy in acute coronary syndromes. Ann Intern Med. 2015;163(10):737-746.
Study design: Cohort (retrospective)
Funding source: Foundation
Allocation: Uncertain
Setting: Inpatient (any location) with outpatient follow-up
Synopsis: Using data from a Danish national registry, these investigators included patients aged 30 years to 90 years who were hospitalized with a first episode of unstable angina or acute MI. Patients were identified as having had an early invasive strategy (diagnostic coronary angiogram within 72 hours of hospitalization) or a conservative invasive strategy (coronary angiogram after 72 hours or no angiogram). The primary outcome was cardiac death or rehospitalization for MI within 60 days.
The investigators used propensity score matching to balance the baseline characteristics of the 2 groups in the initial cohort of 54,000 patients, resulting in 9852 matched patient-pairs. Notably, 42% of the conservative-strategy patients in the propensity-matched cohort received no cardiac catheterization. Overall, treatment with an early invasive strategy was associated with lower risks of cardiac death (5.9% vs 7.6%; number needed to treat [NNT] = 59; P < .001), all-cause death (7.3% vs 10.6%; NNT = 30; P < .001), and rehospitalization for MI (3.4% vs 5%; NNT = 63; P < .001).
However, as an accompanying editorial suggests, the causal inference is not necessarily valid. Given the use of an administrative database, the investigators lacked important clinical information, including indications for the angiograms performed, troponin levels, ejection fractions, and electrocardiogram findings. Without these key data, it is difficult to say whether they were comparing apples to apples, even after propensity score matching. Additionally, the study really just measures the timing of the initial angiogram without taking into account procedures done later that may have affected outcomes. As such, the validity of this study is questionable and, although the results agree with previous randomized clinical trial outcomes, it neither strengthens nor weakens what is already known.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Nick Fitterman, MD, SFHM, Discusses Population Health and Hospital Medicine's Role
Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., and North Shore-Long Island Jewish Health System in New Hyde Park, N.Y., discusses how hospital medicine factors into population health—where is the intersection and what is the hospitalist’s role?
Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., and North Shore-Long Island Jewish Health System in New Hyde Park, N.Y., discusses how hospital medicine factors into population health—where is the intersection and what is the hospitalist’s role?
Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., and North Shore-Long Island Jewish Health System in New Hyde Park, N.Y., discusses how hospital medicine factors into population health—where is the intersection and what is the hospitalist’s role?
Dr. Jaime Upegui, MD, Chats about Motorcycles, Skydiving, and Zen
Movement is key to hospitalist Jaime Upegui, MD, who says riding a motorcycle is a lot like yoga, "you have to focus on the moment, the task at hand." Listen to more of our interview:
Movement is key to hospitalist Jaime Upegui, MD, who says riding a motorcycle is a lot like yoga, "you have to focus on the moment, the task at hand." Listen to more of our interview:
Movement is key to hospitalist Jaime Upegui, MD, who says riding a motorcycle is a lot like yoga, "you have to focus on the moment, the task at hand." Listen to more of our interview:
Harvard Professor Robert Blendon, ScD, Discusses the Republican Presidential Candidates
Listen to more of our interview on the GOP candidates with Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass.
Listen to more of our interview on the GOP candidates with Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass.
Listen to more of our interview on the GOP candidates with Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass.
QUIZ: What Is Your Risk from a Needlestick?
Highlights of the January 2016 issue of The Hospitalist
Why Hospitalists Should Embrace Population Health
Population health focuses on the specific health needs of an individual within a defined population.
“In order to truly measure a patient’s health outcomes and identify best practices, providers must evaluate a group of people with similar health needs,” explains Joseph Damore, vice president of population health management for Charlotte-N.C.-based Premier, Inc. “Once we understand a population’s outcomes, we can then target the individual.”
Fundamentally, population health is about individualized care and intervening earlier in order to get a better outcome based on what generally works for the population. It’s also about identifying populations that need specific, targeted care, such as diabetic and oncology patients.
Back in 2003, David A. Kindig MD, PhD, and Greg Stoddart, PhD, defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”1
In order to achieve population health, according to Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., “it is necessary to reduce health inequities or disparities among different populations due to, among other factors, the social determinants of health, which include social, environmental, cultural, and physical factors.”
Even though the concept of population health emerged more than 25 years ago, Dr. Fitterman points out that, until recently, the U.S. healthcare system has looked at an individual’s episodic illness rather than at population health, which focuses on wellness, prevention, and coordinated care across the continuum.
Marianne McPherson, PhD, MS, senior director of programs, research, and evaluation for the National Institute for Children’s Health Quality in Boston, says it is important for hospitalists to focus on both the patient and the population.
“You need to understand the particular factors facing the patient in front of you and understand that that individual is a product of a variety of different circumstances,” she says. “If you only look at an individual’s health, you can miss important trends across a group of patients within a population or community.
“By looking at both the individual and entire population, you can provide the most effective healthcare and health promotion.”
Government Spearheads Initiatives
With passage of the Patient Protection and Affordable Care Act (ACA) of 2010, the U.S. government helped accelerate the movement toward population health. According to Joshua D. Lenchus, DO, RPh, FACP, SFHM, a veteran hospitalist, president of Jackson Health System Medical Staff, and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine, the act’s provisions aim to improve the quality of care and create accountable care organizations (ACOs).
“The idea was to provide patients with insurance coverage, which would improve the access to care of which they were previously deprived,” he says. “With better access, they may receive quality healthcare and the identification and mitigation of disease at an early stage, thereby reducing overall healthcare costs, with the commensurate benefit of a healthy patient population.
“Of course, this is fraught with naïveté, because it explicitly dismisses nonmedical health determinants (i.e., socioeconomic status, education, literacy rate, transportation availability, employment status, individual patient responsibility, and so forth).”
Now, with ACOs, a hospital or healthcare system can manage patient risk with a potential financial gain—if they manage it well. The government shifts the episodic cost of care to an ACO, charges it with achieving health outcome metrics, and allows it to reap the reward of doing so in a cost-effective manner. More risk equals more reward, potentially. But to affect positive change in patient outcomes (e.g. health) in this manner requires acknowledging such external determinants. Hospitals, hospitalists, and physician leaders must seriously consider health determinants and how they impact patients if they are going to adequately address population health.
David Nash, MD, MBA, founding dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia, sees the ACA as the major driver of population health, with the payment structure moving from a world of volume to one of value.
“It’s all about demonstrating an improvement in the population’s health,” he says.
In January 2015, U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell announced that by 2018, 50 cents of every Medicare dollar will be attached to some measure of outcome.2
“So this move, from volume to value, will be the underpinning of the entire population health movement,” Dr. Nash says, “and we will be rewarded based on an improvement in a population’s health, instead of rewards for using resources on a per person basis.”
What’s a Hospitalist to Do?
Hospitalists typically are focused on inpatient care, managing a patient stay and coordinating discharge. Population health is an area, experts say, where hospitalists can extend their expertise in patient care and take a leadership role beyond the hospital.
“Hospitalists need to be aware of population health, embrace it, and help to develop structures within their programs that allow them to more closely partner with social services and case managers,” Dr. Fitterman says. “[You can] coordinate this type of care.”
Listen to more of our interview with Dr. Fitterman.
Dr. Lenchus agrees, noting that hospitalists intersect with population health most at discharge.
“The time point during which we must reconcile our discharge plan with the realities of the patient’s everyday life,” he says. “As we encourage an increasingly active lifestyle, we must pause to ascertain whether or not the patient lives in a neighborhood that is safe for outdoor activity.
As better nutrition is suggested, we must understand that the cost of a meal at a fast food chain is likely cheaper than one at a health food store. And, when arranging for a follow-up appointment, we must account for the bus schedule if a patient depends on that mode of transportation, as well as the potential to be released from work if employed.
“All of these external health determinants play a significant role in patients’ ability to adhere to instructions. Failure to [consider them in the discharge plan] will inevitably result in worsened health outcomes for the patient, and possibly hospital readmission.”
Hospitalists should be aware of the community-based organizations and services that exist, maintaining a working knowledge of who can provide volunteers, aid, food, and clothing to patients in need.
“Hospitalists should help lead or coordinate efforts to catalog these services in a community in which we practice, so we can steer patients toward these facilities,” Dr. Fitterman says. “In the past, we would treat acute medical issues and walk away. Now we need to be involved in patients’ needs, and those of their families.”
Establish a Team
A team-based approach is key to improving patient outcomes upon discharge, Dr. Lenchus says. Hospitalists should interact with social workers and case managers in anticipation of discharge; include the pharmacist in discharge medication counseling sessions. Are there relevant pharmaceutical industry-sponsored programs that can help the patient obtain prescription medications? Does the patient already qualify for some assistance? If the patient is insured, is the medication being prescribed on the formulary, or can it be modified so that it is covered? Could a generic version be prescribed? Does the patient understand the reason for hospitalization, have a follow-up appointment, and know how to take his medications?
Dr. Nash sees physicians as the team captains; physicians know how the system works, because they see it up close every day. The team includes key personnel, such as nurse practitioners, physician assistants, pharmacists, patient navigators, social workers, and patient educators.
“A physician, who might be a hospitalist, ideally will have additional training in both leadership and in population health,” Dr. Nash says.
He also encourages hospitalists to become patient advocates and educators, even though this is not their traditional role.
“They can do a lot to help a hospitalized patient face their challenges,” he says. “Encourage patients to stop smoking, go on a diet, and exercise. When a physician engages in this conversation, it aids in a patient’s ability to tackle challenges.”
For hospitalists who already feel overstretched with demands and overwhelmed with taking on the task of managing population health, Dr. McPherson suggests they learn more about the trend by studying it as part of their continuing education requirements. In addition, many hospitals have a department dedicated to patient safety or quality assurance.
“Ask how they can help the hospital to provide better patient care,” Dr. McPherson says. “Ask patients about their concerns or those of their neighbors. You may start to see trends.”
For example, if you suspect a trend of children who live in a certain housing development having difficulty breathing, try to find out if other hospital units are aware of this. Also try to ascertain whether or not any community groups connected to the hospital are already working to make the housing safer.
Population Health Challenges
The transition to being accountable for the health of a population will most likely be challenging for all providers. It involves significant risk, especially during the transition period, when an organization must live in both worlds (fee-for-service and value-based payment), says Damore, Premier’s vice president of population health management. He says it also requires:
- Enlightened and supportive leadership;
- Information technology to analyze claims and other infrastructure;
- New care management programs to coordinate care across the continuum;
- Agreements that align payment with population health management; and
- Skills and ability to transform a culture to a new value-based model.
To overcome the challenge of incorporating population health, Dr. McPherson suggests hospitals look to their large network of peers and learn from those already doing this, rather than reinventing the wheel. Look for champions to spearhead such initiatives.
“Identify folks who are already oriented in this direction and took steps in this vein,” she says.
Time and money are potential concerns, especially if embarking on a population health initiative will be an additional expense.
“A potential solution would be to look at ways to shift the focus, so that population health becomes integral to proper patient care, from promoting health and well-being to treating illness,” Dr. McPherson says. For example, by minimizing environmentally associated risks, hospitalists might be able to decrease the number of admissions, which will result in a return on your investment and improve population health.
Population health is here to stay, as payment models shift from fee-for-service to the value-based model. Hospitalists should embrace the movement and spearhead initiatives to get others on board. A hospital-wide team approach is advised. And, to save time and money, seek guidance from others who have already been successful. TH
Karen Appold is a medical writer in Pennsylvania.
References
1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003:93(3):380-383. doi: 10.2105/AJPH.93.3.380
2. Mathews Burwell S. Progress towards achieving better care, smarter spending, healthier people. U.S. Department of Health and Human Services website. January 26, 2015. Available at: http://www.hhs.gov/blog/2015/01/26/progress-towards-better-care-smarter-spending-healthier-people.html. Accessed November 8, 2015.
A Population’s Health Isn’t Just about Healthcare
Improvement in population health requires action on multiple determinants, including medical care, health behaviors, and the social and physical environments; therefore, no single entity can be held accountable for achieving improved outcomes. Medical organizations, the government, schools, businesses, and community organizations all need to make substantial changes in how they approach health and allocate resources.1
“Community organizations have important roles, such as social services and urban planning, and businesses need to understand that they have to invest in their communities if they want a healthy future workforce,” says David A. Kindig MD, PhD, emeritus professor of population health sciences at the University of Wisconsin Madison School of Medicine and Public Health. “Everyone has a role to play.”
Healthcare organizations need to reach beyond their traditional roles to support these interventions.
“It is a team sport in 2015,” Dr. Kindig says. “For many decades, medical care was considered the most prominent factor for a population’s health. Of course it remains so, but from a population health perspective, these other factors are equally or even more important.”
According to county health rankings and roadmaps compiled for the entire United States by the University of Wisconsin, the following factors play a role in population health: clinical care, 20%; health behaviors (e.g. tobacco use, diet and exercise, sexual activity), 30%; social and economic factors (e.g. jobs, education, and social support), 40%; and physical environment (i.e., air and water quality, housing, and transit), 10%.2
The bottom line is that most determinants of health (80%) are nonclinical.
“Social determinants are the principal driver of well-being,” says David Nash, MD, MBA, founding dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia. “It’s mostly about what someone does every day to stay healthy.” TH
References
1. Kindig DA, Isham G. Population health improvement: a community health business model that engages partners in all sectors. Front Health Serv Manage. 2014;30(4):3-20.
2. Our approach. County Health Rankings & Roadmaps website. Available at: http://www.countyhealthrankings.org/our-approach. Accessed November 8, 2015.
Population health focuses on the specific health needs of an individual within a defined population.
“In order to truly measure a patient’s health outcomes and identify best practices, providers must evaluate a group of people with similar health needs,” explains Joseph Damore, vice president of population health management for Charlotte-N.C.-based Premier, Inc. “Once we understand a population’s outcomes, we can then target the individual.”
Fundamentally, population health is about individualized care and intervening earlier in order to get a better outcome based on what generally works for the population. It’s also about identifying populations that need specific, targeted care, such as diabetic and oncology patients.
Back in 2003, David A. Kindig MD, PhD, and Greg Stoddart, PhD, defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”1
In order to achieve population health, according to Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., “it is necessary to reduce health inequities or disparities among different populations due to, among other factors, the social determinants of health, which include social, environmental, cultural, and physical factors.”
Even though the concept of population health emerged more than 25 years ago, Dr. Fitterman points out that, until recently, the U.S. healthcare system has looked at an individual’s episodic illness rather than at population health, which focuses on wellness, prevention, and coordinated care across the continuum.
Marianne McPherson, PhD, MS, senior director of programs, research, and evaluation for the National Institute for Children’s Health Quality in Boston, says it is important for hospitalists to focus on both the patient and the population.
“You need to understand the particular factors facing the patient in front of you and understand that that individual is a product of a variety of different circumstances,” she says. “If you only look at an individual’s health, you can miss important trends across a group of patients within a population or community.
“By looking at both the individual and entire population, you can provide the most effective healthcare and health promotion.”
Government Spearheads Initiatives
With passage of the Patient Protection and Affordable Care Act (ACA) of 2010, the U.S. government helped accelerate the movement toward population health. According to Joshua D. Lenchus, DO, RPh, FACP, SFHM, a veteran hospitalist, president of Jackson Health System Medical Staff, and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine, the act’s provisions aim to improve the quality of care and create accountable care organizations (ACOs).
“The idea was to provide patients with insurance coverage, which would improve the access to care of which they were previously deprived,” he says. “With better access, they may receive quality healthcare and the identification and mitigation of disease at an early stage, thereby reducing overall healthcare costs, with the commensurate benefit of a healthy patient population.
“Of course, this is fraught with naïveté, because it explicitly dismisses nonmedical health determinants (i.e., socioeconomic status, education, literacy rate, transportation availability, employment status, individual patient responsibility, and so forth).”
Now, with ACOs, a hospital or healthcare system can manage patient risk with a potential financial gain—if they manage it well. The government shifts the episodic cost of care to an ACO, charges it with achieving health outcome metrics, and allows it to reap the reward of doing so in a cost-effective manner. More risk equals more reward, potentially. But to affect positive change in patient outcomes (e.g. health) in this manner requires acknowledging such external determinants. Hospitals, hospitalists, and physician leaders must seriously consider health determinants and how they impact patients if they are going to adequately address population health.
David Nash, MD, MBA, founding dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia, sees the ACA as the major driver of population health, with the payment structure moving from a world of volume to one of value.
“It’s all about demonstrating an improvement in the population’s health,” he says.
In January 2015, U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell announced that by 2018, 50 cents of every Medicare dollar will be attached to some measure of outcome.2
“So this move, from volume to value, will be the underpinning of the entire population health movement,” Dr. Nash says, “and we will be rewarded based on an improvement in a population’s health, instead of rewards for using resources on a per person basis.”
What’s a Hospitalist to Do?
Hospitalists typically are focused on inpatient care, managing a patient stay and coordinating discharge. Population health is an area, experts say, where hospitalists can extend their expertise in patient care and take a leadership role beyond the hospital.
“Hospitalists need to be aware of population health, embrace it, and help to develop structures within their programs that allow them to more closely partner with social services and case managers,” Dr. Fitterman says. “[You can] coordinate this type of care.”
Listen to more of our interview with Dr. Fitterman.
Dr. Lenchus agrees, noting that hospitalists intersect with population health most at discharge.
“The time point during which we must reconcile our discharge plan with the realities of the patient’s everyday life,” he says. “As we encourage an increasingly active lifestyle, we must pause to ascertain whether or not the patient lives in a neighborhood that is safe for outdoor activity.
As better nutrition is suggested, we must understand that the cost of a meal at a fast food chain is likely cheaper than one at a health food store. And, when arranging for a follow-up appointment, we must account for the bus schedule if a patient depends on that mode of transportation, as well as the potential to be released from work if employed.
“All of these external health determinants play a significant role in patients’ ability to adhere to instructions. Failure to [consider them in the discharge plan] will inevitably result in worsened health outcomes for the patient, and possibly hospital readmission.”
Hospitalists should be aware of the community-based organizations and services that exist, maintaining a working knowledge of who can provide volunteers, aid, food, and clothing to patients in need.
“Hospitalists should help lead or coordinate efforts to catalog these services in a community in which we practice, so we can steer patients toward these facilities,” Dr. Fitterman says. “In the past, we would treat acute medical issues and walk away. Now we need to be involved in patients’ needs, and those of their families.”
Establish a Team
A team-based approach is key to improving patient outcomes upon discharge, Dr. Lenchus says. Hospitalists should interact with social workers and case managers in anticipation of discharge; include the pharmacist in discharge medication counseling sessions. Are there relevant pharmaceutical industry-sponsored programs that can help the patient obtain prescription medications? Does the patient already qualify for some assistance? If the patient is insured, is the medication being prescribed on the formulary, or can it be modified so that it is covered? Could a generic version be prescribed? Does the patient understand the reason for hospitalization, have a follow-up appointment, and know how to take his medications?
Dr. Nash sees physicians as the team captains; physicians know how the system works, because they see it up close every day. The team includes key personnel, such as nurse practitioners, physician assistants, pharmacists, patient navigators, social workers, and patient educators.
“A physician, who might be a hospitalist, ideally will have additional training in both leadership and in population health,” Dr. Nash says.
He also encourages hospitalists to become patient advocates and educators, even though this is not their traditional role.
“They can do a lot to help a hospitalized patient face their challenges,” he says. “Encourage patients to stop smoking, go on a diet, and exercise. When a physician engages in this conversation, it aids in a patient’s ability to tackle challenges.”
For hospitalists who already feel overstretched with demands and overwhelmed with taking on the task of managing population health, Dr. McPherson suggests they learn more about the trend by studying it as part of their continuing education requirements. In addition, many hospitals have a department dedicated to patient safety or quality assurance.
“Ask how they can help the hospital to provide better patient care,” Dr. McPherson says. “Ask patients about their concerns or those of their neighbors. You may start to see trends.”
For example, if you suspect a trend of children who live in a certain housing development having difficulty breathing, try to find out if other hospital units are aware of this. Also try to ascertain whether or not any community groups connected to the hospital are already working to make the housing safer.
Population Health Challenges
The transition to being accountable for the health of a population will most likely be challenging for all providers. It involves significant risk, especially during the transition period, when an organization must live in both worlds (fee-for-service and value-based payment), says Damore, Premier’s vice president of population health management. He says it also requires:
- Enlightened and supportive leadership;
- Information technology to analyze claims and other infrastructure;
- New care management programs to coordinate care across the continuum;
- Agreements that align payment with population health management; and
- Skills and ability to transform a culture to a new value-based model.
To overcome the challenge of incorporating population health, Dr. McPherson suggests hospitals look to their large network of peers and learn from those already doing this, rather than reinventing the wheel. Look for champions to spearhead such initiatives.
“Identify folks who are already oriented in this direction and took steps in this vein,” she says.
Time and money are potential concerns, especially if embarking on a population health initiative will be an additional expense.
“A potential solution would be to look at ways to shift the focus, so that population health becomes integral to proper patient care, from promoting health and well-being to treating illness,” Dr. McPherson says. For example, by minimizing environmentally associated risks, hospitalists might be able to decrease the number of admissions, which will result in a return on your investment and improve population health.
Population health is here to stay, as payment models shift from fee-for-service to the value-based model. Hospitalists should embrace the movement and spearhead initiatives to get others on board. A hospital-wide team approach is advised. And, to save time and money, seek guidance from others who have already been successful. TH
Karen Appold is a medical writer in Pennsylvania.
References
1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003:93(3):380-383. doi: 10.2105/AJPH.93.3.380
2. Mathews Burwell S. Progress towards achieving better care, smarter spending, healthier people. U.S. Department of Health and Human Services website. January 26, 2015. Available at: http://www.hhs.gov/blog/2015/01/26/progress-towards-better-care-smarter-spending-healthier-people.html. Accessed November 8, 2015.
A Population’s Health Isn’t Just about Healthcare
Improvement in population health requires action on multiple determinants, including medical care, health behaviors, and the social and physical environments; therefore, no single entity can be held accountable for achieving improved outcomes. Medical organizations, the government, schools, businesses, and community organizations all need to make substantial changes in how they approach health and allocate resources.1
“Community organizations have important roles, such as social services and urban planning, and businesses need to understand that they have to invest in their communities if they want a healthy future workforce,” says David A. Kindig MD, PhD, emeritus professor of population health sciences at the University of Wisconsin Madison School of Medicine and Public Health. “Everyone has a role to play.”
Healthcare organizations need to reach beyond their traditional roles to support these interventions.
“It is a team sport in 2015,” Dr. Kindig says. “For many decades, medical care was considered the most prominent factor for a population’s health. Of course it remains so, but from a population health perspective, these other factors are equally or even more important.”
According to county health rankings and roadmaps compiled for the entire United States by the University of Wisconsin, the following factors play a role in population health: clinical care, 20%; health behaviors (e.g. tobacco use, diet and exercise, sexual activity), 30%; social and economic factors (e.g. jobs, education, and social support), 40%; and physical environment (i.e., air and water quality, housing, and transit), 10%.2
The bottom line is that most determinants of health (80%) are nonclinical.
“Social determinants are the principal driver of well-being,” says David Nash, MD, MBA, founding dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia. “It’s mostly about what someone does every day to stay healthy.” TH
References
1. Kindig DA, Isham G. Population health improvement: a community health business model that engages partners in all sectors. Front Health Serv Manage. 2014;30(4):3-20.
2. Our approach. County Health Rankings & Roadmaps website. Available at: http://www.countyhealthrankings.org/our-approach. Accessed November 8, 2015.
Population health focuses on the specific health needs of an individual within a defined population.
“In order to truly measure a patient’s health outcomes and identify best practices, providers must evaluate a group of people with similar health needs,” explains Joseph Damore, vice president of population health management for Charlotte-N.C.-based Premier, Inc. “Once we understand a population’s outcomes, we can then target the individual.”
Fundamentally, population health is about individualized care and intervening earlier in order to get a better outcome based on what generally works for the population. It’s also about identifying populations that need specific, targeted care, such as diabetic and oncology patients.
Back in 2003, David A. Kindig MD, PhD, and Greg Stoddart, PhD, defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”1
In order to achieve population health, according to Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., “it is necessary to reduce health inequities or disparities among different populations due to, among other factors, the social determinants of health, which include social, environmental, cultural, and physical factors.”
Even though the concept of population health emerged more than 25 years ago, Dr. Fitterman points out that, until recently, the U.S. healthcare system has looked at an individual’s episodic illness rather than at population health, which focuses on wellness, prevention, and coordinated care across the continuum.
Marianne McPherson, PhD, MS, senior director of programs, research, and evaluation for the National Institute for Children’s Health Quality in Boston, says it is important for hospitalists to focus on both the patient and the population.
“You need to understand the particular factors facing the patient in front of you and understand that that individual is a product of a variety of different circumstances,” she says. “If you only look at an individual’s health, you can miss important trends across a group of patients within a population or community.
“By looking at both the individual and entire population, you can provide the most effective healthcare and health promotion.”
Government Spearheads Initiatives
With passage of the Patient Protection and Affordable Care Act (ACA) of 2010, the U.S. government helped accelerate the movement toward population health. According to Joshua D. Lenchus, DO, RPh, FACP, SFHM, a veteran hospitalist, president of Jackson Health System Medical Staff, and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine, the act’s provisions aim to improve the quality of care and create accountable care organizations (ACOs).
“The idea was to provide patients with insurance coverage, which would improve the access to care of which they were previously deprived,” he says. “With better access, they may receive quality healthcare and the identification and mitigation of disease at an early stage, thereby reducing overall healthcare costs, with the commensurate benefit of a healthy patient population.
“Of course, this is fraught with naïveté, because it explicitly dismisses nonmedical health determinants (i.e., socioeconomic status, education, literacy rate, transportation availability, employment status, individual patient responsibility, and so forth).”
Now, with ACOs, a hospital or healthcare system can manage patient risk with a potential financial gain—if they manage it well. The government shifts the episodic cost of care to an ACO, charges it with achieving health outcome metrics, and allows it to reap the reward of doing so in a cost-effective manner. More risk equals more reward, potentially. But to affect positive change in patient outcomes (e.g. health) in this manner requires acknowledging such external determinants. Hospitals, hospitalists, and physician leaders must seriously consider health determinants and how they impact patients if they are going to adequately address population health.
David Nash, MD, MBA, founding dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia, sees the ACA as the major driver of population health, with the payment structure moving from a world of volume to one of value.
“It’s all about demonstrating an improvement in the population’s health,” he says.
In January 2015, U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell announced that by 2018, 50 cents of every Medicare dollar will be attached to some measure of outcome.2
“So this move, from volume to value, will be the underpinning of the entire population health movement,” Dr. Nash says, “and we will be rewarded based on an improvement in a population’s health, instead of rewards for using resources on a per person basis.”
What’s a Hospitalist to Do?
Hospitalists typically are focused on inpatient care, managing a patient stay and coordinating discharge. Population health is an area, experts say, where hospitalists can extend their expertise in patient care and take a leadership role beyond the hospital.
“Hospitalists need to be aware of population health, embrace it, and help to develop structures within their programs that allow them to more closely partner with social services and case managers,” Dr. Fitterman says. “[You can] coordinate this type of care.”
Listen to more of our interview with Dr. Fitterman.
Dr. Lenchus agrees, noting that hospitalists intersect with population health most at discharge.
“The time point during which we must reconcile our discharge plan with the realities of the patient’s everyday life,” he says. “As we encourage an increasingly active lifestyle, we must pause to ascertain whether or not the patient lives in a neighborhood that is safe for outdoor activity.
As better nutrition is suggested, we must understand that the cost of a meal at a fast food chain is likely cheaper than one at a health food store. And, when arranging for a follow-up appointment, we must account for the bus schedule if a patient depends on that mode of transportation, as well as the potential to be released from work if employed.
“All of these external health determinants play a significant role in patients’ ability to adhere to instructions. Failure to [consider them in the discharge plan] will inevitably result in worsened health outcomes for the patient, and possibly hospital readmission.”
Hospitalists should be aware of the community-based organizations and services that exist, maintaining a working knowledge of who can provide volunteers, aid, food, and clothing to patients in need.
“Hospitalists should help lead or coordinate efforts to catalog these services in a community in which we practice, so we can steer patients toward these facilities,” Dr. Fitterman says. “In the past, we would treat acute medical issues and walk away. Now we need to be involved in patients’ needs, and those of their families.”
Establish a Team
A team-based approach is key to improving patient outcomes upon discharge, Dr. Lenchus says. Hospitalists should interact with social workers and case managers in anticipation of discharge; include the pharmacist in discharge medication counseling sessions. Are there relevant pharmaceutical industry-sponsored programs that can help the patient obtain prescription medications? Does the patient already qualify for some assistance? If the patient is insured, is the medication being prescribed on the formulary, or can it be modified so that it is covered? Could a generic version be prescribed? Does the patient understand the reason for hospitalization, have a follow-up appointment, and know how to take his medications?
Dr. Nash sees physicians as the team captains; physicians know how the system works, because they see it up close every day. The team includes key personnel, such as nurse practitioners, physician assistants, pharmacists, patient navigators, social workers, and patient educators.
“A physician, who might be a hospitalist, ideally will have additional training in both leadership and in population health,” Dr. Nash says.
He also encourages hospitalists to become patient advocates and educators, even though this is not their traditional role.
“They can do a lot to help a hospitalized patient face their challenges,” he says. “Encourage patients to stop smoking, go on a diet, and exercise. When a physician engages in this conversation, it aids in a patient’s ability to tackle challenges.”
For hospitalists who already feel overstretched with demands and overwhelmed with taking on the task of managing population health, Dr. McPherson suggests they learn more about the trend by studying it as part of their continuing education requirements. In addition, many hospitals have a department dedicated to patient safety or quality assurance.
“Ask how they can help the hospital to provide better patient care,” Dr. McPherson says. “Ask patients about their concerns or those of their neighbors. You may start to see trends.”
For example, if you suspect a trend of children who live in a certain housing development having difficulty breathing, try to find out if other hospital units are aware of this. Also try to ascertain whether or not any community groups connected to the hospital are already working to make the housing safer.
Population Health Challenges
The transition to being accountable for the health of a population will most likely be challenging for all providers. It involves significant risk, especially during the transition period, when an organization must live in both worlds (fee-for-service and value-based payment), says Damore, Premier’s vice president of population health management. He says it also requires:
- Enlightened and supportive leadership;
- Information technology to analyze claims and other infrastructure;
- New care management programs to coordinate care across the continuum;
- Agreements that align payment with population health management; and
- Skills and ability to transform a culture to a new value-based model.
To overcome the challenge of incorporating population health, Dr. McPherson suggests hospitals look to their large network of peers and learn from those already doing this, rather than reinventing the wheel. Look for champions to spearhead such initiatives.
“Identify folks who are already oriented in this direction and took steps in this vein,” she says.
Time and money are potential concerns, especially if embarking on a population health initiative will be an additional expense.
“A potential solution would be to look at ways to shift the focus, so that population health becomes integral to proper patient care, from promoting health and well-being to treating illness,” Dr. McPherson says. For example, by minimizing environmentally associated risks, hospitalists might be able to decrease the number of admissions, which will result in a return on your investment and improve population health.
Population health is here to stay, as payment models shift from fee-for-service to the value-based model. Hospitalists should embrace the movement and spearhead initiatives to get others on board. A hospital-wide team approach is advised. And, to save time and money, seek guidance from others who have already been successful. TH
Karen Appold is a medical writer in Pennsylvania.
References
1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003:93(3):380-383. doi: 10.2105/AJPH.93.3.380
2. Mathews Burwell S. Progress towards achieving better care, smarter spending, healthier people. U.S. Department of Health and Human Services website. January 26, 2015. Available at: http://www.hhs.gov/blog/2015/01/26/progress-towards-better-care-smarter-spending-healthier-people.html. Accessed November 8, 2015.
A Population’s Health Isn’t Just about Healthcare
Improvement in population health requires action on multiple determinants, including medical care, health behaviors, and the social and physical environments; therefore, no single entity can be held accountable for achieving improved outcomes. Medical organizations, the government, schools, businesses, and community organizations all need to make substantial changes in how they approach health and allocate resources.1
“Community organizations have important roles, such as social services and urban planning, and businesses need to understand that they have to invest in their communities if they want a healthy future workforce,” says David A. Kindig MD, PhD, emeritus professor of population health sciences at the University of Wisconsin Madison School of Medicine and Public Health. “Everyone has a role to play.”
Healthcare organizations need to reach beyond their traditional roles to support these interventions.
“It is a team sport in 2015,” Dr. Kindig says. “For many decades, medical care was considered the most prominent factor for a population’s health. Of course it remains so, but from a population health perspective, these other factors are equally or even more important.”
According to county health rankings and roadmaps compiled for the entire United States by the University of Wisconsin, the following factors play a role in population health: clinical care, 20%; health behaviors (e.g. tobacco use, diet and exercise, sexual activity), 30%; social and economic factors (e.g. jobs, education, and social support), 40%; and physical environment (i.e., air and water quality, housing, and transit), 10%.2
The bottom line is that most determinants of health (80%) are nonclinical.
“Social determinants are the principal driver of well-being,” says David Nash, MD, MBA, founding dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia. “It’s mostly about what someone does every day to stay healthy.” TH
References
1. Kindig DA, Isham G. Population health improvement: a community health business model that engages partners in all sectors. Front Health Serv Manage. 2014;30(4):3-20.
2. Our approach. County Health Rankings & Roadmaps website. Available at: http://www.countyhealthrankings.org/our-approach. Accessed November 8, 2015.
