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A surgical hospitalist program that's been shown to improve clinical outcomes and reduce inpatient length of stay (LOS) in a non-trauma setting is replicable across the country, says the author of a recent study.

Published in the Journal of the American College of Surgeons, the study reports that a team of surgeons dedicated solely to acute-care surgeries at Sutter Medical Center in Sacramento, Calif., decreased patients' LOS (6.5 days to 5.7 days, P<0.0016), hospital costs ($12,009 to $8306, P<0.0001), and overall complications (21% to 12%, P<0.0001).

Readmissions also "showed a downward trend" but not enough to be statistically significant. The retrospective review looked at the five-year period from 2007 to 2011, which represented the year before the service was initiated and the subsequent four years in which it was practiced.

"By decreasing variation, we improved outcomes and we improved efficiencies," says study author Leon Owens, MD, FACS, president and chief executive officer of the Sacramento-based Surgical Affiliates Management Group, which provided the surgical coverage for Sutter Medical Center. "So we wound up saving money and taking better care of patients. We succeeded because of the uniformity of how we approached the problems and because our team of surgeons is dedicated to doing these surgeries. They do not additionally need to do an elective surgery or deal with other distractions at their office."

Dr. Owens says he believes a well-managed team of acute-care surgeons can improve patient care at any institution that chooses to institute a similar program. "It's not only the brilliance of our doctors but the methodology," he adds. "Our doctors are bright and good, but if you get group-oriented, team-willing, competent surgeons, I believe this is reproducible. We believe this is going to be a common practice across the country. It's just a matter of time to get there." TH

Visit our website for more information on surgical hospitalists.

A surgical hospitalist program that's been shown to improve clinical outcomes and reduce inpatient length of stay (LOS) in a non-trauma setting is replicable across the country, says the author of a recent study.

Published in the Journal of the American College of Surgeons, the study reports that a team of surgeons dedicated solely to acute-care surgeries at Sutter Medical Center in Sacramento, Calif., decreased patients' LOS (6.5 days to 5.7 days, P<0.0016), hospital costs ($12,009 to $8306, P<0.0001), and overall complications (21% to 12%, P<0.0001).

Readmissions also "showed a downward trend" but not enough to be statistically significant. The retrospective review looked at the five-year period from 2007 to 2011, which represented the year before the service was initiated and the subsequent four years in which it was practiced.

"By decreasing variation, we improved outcomes and we improved efficiencies," says study author Leon Owens, MD, FACS, president and chief executive officer of the Sacramento-based Surgical Affiliates Management Group, which provided the surgical coverage for Sutter Medical Center. "So we wound up saving money and taking better care of patients. We succeeded because of the uniformity of how we approached the problems and because our team of surgeons is dedicated to doing these surgeries. They do not additionally need to do an elective surgery or deal with other distractions at their office."

Dr. Owens says he believes a well-managed team of acute-care surgeons can improve patient care at any institution that chooses to institute a similar program. "It's not only the brilliance of our doctors but the methodology," he adds. "Our doctors are bright and good, but if you get group-oriented, team-willing, competent surgeons, I believe this is reproducible. We believe this is going to be a common practice across the country. It's just a matter of time to get there." TH

Visit our website for more information on surgical hospitalists.

A surgical hospitalist program that's been shown to improve clinical outcomes and reduce inpatient length of stay (LOS) in a non-trauma setting is replicable across the country, says the author of a recent study.

Published in the Journal of the American College of Surgeons, the study reports that a team of surgeons dedicated solely to acute-care surgeries at Sutter Medical Center in Sacramento, Calif., decreased patients' LOS (6.5 days to 5.7 days, P<0.0016), hospital costs ($12,009 to $8306, P<0.0001), and overall complications (21% to 12%, P<0.0001).

Readmissions also "showed a downward trend" but not enough to be statistically significant. The retrospective review looked at the five-year period from 2007 to 2011, which represented the year before the service was initiated and the subsequent four years in which it was practiced.

"By decreasing variation, we improved outcomes and we improved efficiencies," says study author Leon Owens, MD, FACS, president and chief executive officer of the Sacramento-based Surgical Affiliates Management Group, which provided the surgical coverage for Sutter Medical Center. "So we wound up saving money and taking better care of patients. We succeeded because of the uniformity of how we approached the problems and because our team of surgeons is dedicated to doing these surgeries. They do not additionally need to do an elective surgery or deal with other distractions at their office."

Dr. Owens says he believes a well-managed team of acute-care surgeons can improve patient care at any institution that chooses to institute a similar program. "It's not only the brilliance of our doctors but the methodology," he adds. "Our doctors are bright and good, but if you get group-oriented, team-willing, competent surgeons, I believe this is reproducible. We believe this is going to be a common practice across the country. It's just a matter of time to get there." TH

Visit our website for more information on surgical hospitalists.

Clinical question: Which risk factors are key in the development of non-leg deep vein thromboses (NLDVTs), and what are the expected clinical sequelae from these events?

Background: Critically ill patients are at increased risk of venous thrombosis. Despite adherence to recommended daily thromboprophylaxis, many patients will develop a venous thrombosis in a vein other than the lower extremity. The association between NLDVT and pulmonary embolism (PE) or death is less clearly identified.

Study design: The PROphylaxis for ThromboEmbolism in Critical Care Trial (PROTECT), a multicenter, randomized, blinded, and concealed prospective cohort study occurring between May 2006 and June 2010.

Setting: Sixty-seven international secondary and tertiary care ICUs in both academic and community settings.

Synopsis: Researchers enrolled 3,746 ICU patients in a randomized controlled trial of dalteparin versus standard heparin for thromboprophylaxis. Of these patients, 84 (2.2%) developed a NLDVT. These thromboses were more likely to be deep and located proximally.

Risk factors were assessed using five selected variables: APACHE (acute physiology and chronic health evaluation), BMI, malignancy, and treatment with vasopressors or statins. Outside of indwelling upper extremity central venous catheters, cancer was the only independent predictor of NLDVT.

Compared to patients without any VTE, those with NLDVT were more likely to develop PE (14.9% versus 1.9%) and have longer ICU stays (19 versus nine days). On average, one in seven patients with NLDVT developed PE during the hospital stay. Despite the association with PE, NLDVT was not associated with an increased ICU mortality in an adjusted model. However, the PROTECT trial may have been underpowered to detect a difference. Additional limitations of the study included a relatively small total number of NLDVTs and a lack of standardized screening protocols for both NLDVT and PE.

Bottom line: Despite universal heparin thromboprophylaxis, many medical-surgical critically ill patients may develop NLDVT, placing them at higher risk for longer ICU stays and PE. TH

Citation: Lamontagne F, McIntyre L, Dodek P, et al. Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study. JAMA Intern Med. 2014;174(5):689-696.

Clinical question: Which risk factors are key in the development of non-leg deep vein thromboses (NLDVTs), and what are the expected clinical sequelae from these events?

Background: Critically ill patients are at increased risk of venous thrombosis. Despite adherence to recommended daily thromboprophylaxis, many patients will develop a venous thrombosis in a vein other than the lower extremity. The association between NLDVT and pulmonary embolism (PE) or death is less clearly identified.

Study design: The PROphylaxis for ThromboEmbolism in Critical Care Trial (PROTECT), a multicenter, randomized, blinded, and concealed prospective cohort study occurring between May 2006 and June 2010.

Setting: Sixty-seven international secondary and tertiary care ICUs in both academic and community settings.

Synopsis: Researchers enrolled 3,746 ICU patients in a randomized controlled trial of dalteparin versus standard heparin for thromboprophylaxis. Of these patients, 84 (2.2%) developed a NLDVT. These thromboses were more likely to be deep and located proximally.

Risk factors were assessed using five selected variables: APACHE (acute physiology and chronic health evaluation), BMI, malignancy, and treatment with vasopressors or statins. Outside of indwelling upper extremity central venous catheters, cancer was the only independent predictor of NLDVT.

Compared to patients without any VTE, those with NLDVT were more likely to develop PE (14.9% versus 1.9%) and have longer ICU stays (19 versus nine days). On average, one in seven patients with NLDVT developed PE during the hospital stay. Despite the association with PE, NLDVT was not associated with an increased ICU mortality in an adjusted model. However, the PROTECT trial may have been underpowered to detect a difference. Additional limitations of the study included a relatively small total number of NLDVTs and a lack of standardized screening protocols for both NLDVT and PE.

Bottom line: Despite universal heparin thromboprophylaxis, many medical-surgical critically ill patients may develop NLDVT, placing them at higher risk for longer ICU stays and PE. TH

Citation: Lamontagne F, McIntyre L, Dodek P, et al. Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study. JAMA Intern Med. 2014;174(5):689-696.

Clinical question: Which risk factors are key in the development of non-leg deep vein thromboses (NLDVTs), and what are the expected clinical sequelae from these events?

Background: Critically ill patients are at increased risk of venous thrombosis. Despite adherence to recommended daily thromboprophylaxis, many patients will develop a venous thrombosis in a vein other than the lower extremity. The association between NLDVT and pulmonary embolism (PE) or death is less clearly identified.

Study design: The PROphylaxis for ThromboEmbolism in Critical Care Trial (PROTECT), a multicenter, randomized, blinded, and concealed prospective cohort study occurring between May 2006 and June 2010.

Setting: Sixty-seven international secondary and tertiary care ICUs in both academic and community settings.

Synopsis: Researchers enrolled 3,746 ICU patients in a randomized controlled trial of dalteparin versus standard heparin for thromboprophylaxis. Of these patients, 84 (2.2%) developed a NLDVT. These thromboses were more likely to be deep and located proximally.

Risk factors were assessed using five selected variables: APACHE (acute physiology and chronic health evaluation), BMI, malignancy, and treatment with vasopressors or statins. Outside of indwelling upper extremity central venous catheters, cancer was the only independent predictor of NLDVT.

Compared to patients without any VTE, those with NLDVT were more likely to develop PE (14.9% versus 1.9%) and have longer ICU stays (19 versus nine days). On average, one in seven patients with NLDVT developed PE during the hospital stay. Despite the association with PE, NLDVT was not associated with an increased ICU mortality in an adjusted model. However, the PROTECT trial may have been underpowered to detect a difference. Additional limitations of the study included a relatively small total number of NLDVTs and a lack of standardized screening protocols for both NLDVT and PE.

Bottom line: Despite universal heparin thromboprophylaxis, many medical-surgical critically ill patients may develop NLDVT, placing them at higher risk for longer ICU stays and PE. TH

Citation: Lamontagne F, McIntyre L, Dodek P, et al. Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study. JAMA Intern Med. 2014;174(5):689-696.

A hospitalist and SHM Public Policy Committee member is hopeful that SHM's recently released position paper recommending changes to the way the "observation status" designation is used for admitted hospital patients will help improve patient care.

The increasing use of the Centers for Medicare & Medicaid Services' (CMS) patient observation status designation—which grew 88% from 2006 to 2012—has frustrated hospitalists. Under the rule, patients are ineligible for skilled-nursing facility (SNF) care, may not claim insurance coverage for some medications, and may face uncertain cost-sharing and other financial liabilities for their hospitalization.

SHM outlined its concerns about the policy and suggested solutions in the report titled "The Observation Status Problem: Impact and Recommendations for Change."

CMS has attempted to address the issue by creating the "two-midnight rule." The report notes, however, that amid confusion on the application of the "two-midnight rule," Medicare auditing and enforcement have been pushed back several times, most recently to March 31, 2015.

"We still are unclear about what patient vulnerability is under this," says SHM Public Policy Committee member Ann Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison, who testified before Congress last May on observation status and other Medicare policies.

"We know that patients can't get SNF coverage when they're under observation," Dr. Sheehy says. "We know that patients are subject to unlimited co-pays when they're under observation, as opposed to when they're hospitalized as inpatients under Medicare Part A, which has a one-time deductible."

The SHM white paper outlines both short- and long-term fixes to the policy. In the near term, SHM recommends:

• Educating providers and patients on the purpose of observation status and raising confidence in when and how it should be applied;

• Changing SNF coverage rules to ensure patients’ eligibility; and

• Reforming the Medicare Recovery Audit Contractor program to improve RAC performance and reduce unintended pressures on admission decisions.

In the long term, the report suggests creating modifiers for diagnosis-related group (DRG) payments to assign to patients needing lower-acuity services, as well as crafting a list of DRGs to assign to patients needing short periods of inpatient care.

"The policy overall is very frustrating," Dr. Sheehy adds. "We hope that any rule change that comes out will address the core problems of observation so that patients can get the care they need with fair and appropriate insurance coverage." TH

Visit our website for more information about patient observation status.

A hospitalist and SHM Public Policy Committee member is hopeful that SHM's recently released position paper recommending changes to the way the "observation status" designation is used for admitted hospital patients will help improve patient care.

The increasing use of the Centers for Medicare & Medicaid Services' (CMS) patient observation status designation—which grew 88% from 2006 to 2012—has frustrated hospitalists. Under the rule, patients are ineligible for skilled-nursing facility (SNF) care, may not claim insurance coverage for some medications, and may face uncertain cost-sharing and other financial liabilities for their hospitalization.

SHM outlined its concerns about the policy and suggested solutions in the report titled "The Observation Status Problem: Impact and Recommendations for Change."

CMS has attempted to address the issue by creating the "two-midnight rule." The report notes, however, that amid confusion on the application of the "two-midnight rule," Medicare auditing and enforcement have been pushed back several times, most recently to March 31, 2015.

"We still are unclear about what patient vulnerability is under this," says SHM Public Policy Committee member Ann Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison, who testified before Congress last May on observation status and other Medicare policies.

"We know that patients can't get SNF coverage when they're under observation," Dr. Sheehy says. "We know that patients are subject to unlimited co-pays when they're under observation, as opposed to when they're hospitalized as inpatients under Medicare Part A, which has a one-time deductible."

The SHM white paper outlines both short- and long-term fixes to the policy. In the near term, SHM recommends:

• Educating providers and patients on the purpose of observation status and raising confidence in when and how it should be applied;

• Changing SNF coverage rules to ensure patients’ eligibility; and

• Reforming the Medicare Recovery Audit Contractor program to improve RAC performance and reduce unintended pressures on admission decisions.

In the long term, the report suggests creating modifiers for diagnosis-related group (DRG) payments to assign to patients needing lower-acuity services, as well as crafting a list of DRGs to assign to patients needing short periods of inpatient care.

"The policy overall is very frustrating," Dr. Sheehy adds. "We hope that any rule change that comes out will address the core problems of observation so that patients can get the care they need with fair and appropriate insurance coverage." TH

Visit our website for more information about patient observation status.

A hospitalist and SHM Public Policy Committee member is hopeful that SHM's recently released position paper recommending changes to the way the "observation status" designation is used for admitted hospital patients will help improve patient care.

The increasing use of the Centers for Medicare & Medicaid Services' (CMS) patient observation status designation—which grew 88% from 2006 to 2012—has frustrated hospitalists. Under the rule, patients are ineligible for skilled-nursing facility (SNF) care, may not claim insurance coverage for some medications, and may face uncertain cost-sharing and other financial liabilities for their hospitalization.

SHM outlined its concerns about the policy and suggested solutions in the report titled "The Observation Status Problem: Impact and Recommendations for Change."

CMS has attempted to address the issue by creating the "two-midnight rule." The report notes, however, that amid confusion on the application of the "two-midnight rule," Medicare auditing and enforcement have been pushed back several times, most recently to March 31, 2015.

"We still are unclear about what patient vulnerability is under this," says SHM Public Policy Committee member Ann Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison, who testified before Congress last May on observation status and other Medicare policies.

"We know that patients can't get SNF coverage when they're under observation," Dr. Sheehy says. "We know that patients are subject to unlimited co-pays when they're under observation, as opposed to when they're hospitalized as inpatients under Medicare Part A, which has a one-time deductible."

The SHM white paper outlines both short- and long-term fixes to the policy. In the near term, SHM recommends:

• Educating providers and patients on the purpose of observation status and raising confidence in when and how it should be applied;

• Changing SNF coverage rules to ensure patients’ eligibility; and

• Reforming the Medicare Recovery Audit Contractor program to improve RAC performance and reduce unintended pressures on admission decisions.

In the long term, the report suggests creating modifiers for diagnosis-related group (DRG) payments to assign to patients needing lower-acuity services, as well as crafting a list of DRGs to assign to patients needing short periods of inpatient care.

"The policy overall is very frustrating," Dr. Sheehy adds. "We hope that any rule change that comes out will address the core problems of observation so that patients can get the care they need with fair and appropriate insurance coverage." TH

Visit our website for more information about patient observation status.

In a Senate subcommittee hearing last month, a panel of patient safety experts and physicians raised concerns about the problem of preventable medical errors, which they say can be linked to more than 1,000 patient deaths per day.

For their part, SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, FHM, says hospitalists should demand that their hospitals report better data on patient outcomes.

"When you talk about a patient death, you're talking about the efforts of an entire hospital going into the death or survival of that patient," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York. "If you ask, 'Where did something go wrong?' just looking at the mortality rate doesn't help. What service are you inquiring about? How can you get clean data that’s also useful to the clinician?"

In his testimony before the Subcommittee on Primary Health and Aging, hospitalist Ashish Jha, MD, MPH, referenced a landmark 1999 report from the Institute of Medicine (IOM), "To Err Is Human: Building a Safer Health System," [PDF] which estimated that between 44,000 and 98,000 deaths in the U.S. each year can be attributed to preventable medical errors.

Since the IOM report was published, little has been done to change the systems of care delivery that can lead providers to make errors, said Dr. Jha, an internist at the VA Boston Healthcare System and professor of health policy and management at the Harvard School of Public Health in Boston.

"When a physician orders the wrong medication because two drugs might sound alike, or when a patient develops a central-line infection because a rushed surgeon didn't use proper sterile technique, we now understand that we need to focus on the system that produced the errors," Dr. Jha told Senate subcommittee members.

Both Dr. Jha and panelist Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, said the Centers for Disease Control and Prevention should expand its National Nosocomial Infections Surveillance Program to collect and report data on medical errors.

Several other speakers said hospitals should be mandated to publicly report medical errors.

"Public disclosure is a critical element to preventing these events from happening," said panelist Lisa McGiffert, director of the Consumers Union Safe Patient Project in Austin, Texas. "It informs people about healthcare outcomes and motivates healthcare providers to do more to prevent errors." TH

Visit our website for more information on the impact of medical errors.

In a Senate subcommittee hearing last month, a panel of patient safety experts and physicians raised concerns about the problem of preventable medical errors, which they say can be linked to more than 1,000 patient deaths per day.

For their part, SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, FHM, says hospitalists should demand that their hospitals report better data on patient outcomes.

"When you talk about a patient death, you're talking about the efforts of an entire hospital going into the death or survival of that patient," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York. "If you ask, 'Where did something go wrong?' just looking at the mortality rate doesn't help. What service are you inquiring about? How can you get clean data that’s also useful to the clinician?"

In his testimony before the Subcommittee on Primary Health and Aging, hospitalist Ashish Jha, MD, MPH, referenced a landmark 1999 report from the Institute of Medicine (IOM), "To Err Is Human: Building a Safer Health System," [PDF] which estimated that between 44,000 and 98,000 deaths in the U.S. each year can be attributed to preventable medical errors.

Since the IOM report was published, little has been done to change the systems of care delivery that can lead providers to make errors, said Dr. Jha, an internist at the VA Boston Healthcare System and professor of health policy and management at the Harvard School of Public Health in Boston.

"When a physician orders the wrong medication because two drugs might sound alike, or when a patient develops a central-line infection because a rushed surgeon didn't use proper sterile technique, we now understand that we need to focus on the system that produced the errors," Dr. Jha told Senate subcommittee members.

Both Dr. Jha and panelist Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, said the Centers for Disease Control and Prevention should expand its National Nosocomial Infections Surveillance Program to collect and report data on medical errors.

Several other speakers said hospitals should be mandated to publicly report medical errors.

"Public disclosure is a critical element to preventing these events from happening," said panelist Lisa McGiffert, director of the Consumers Union Safe Patient Project in Austin, Texas. "It informs people about healthcare outcomes and motivates healthcare providers to do more to prevent errors." TH

Visit our website for more information on the impact of medical errors.

In a Senate subcommittee hearing last month, a panel of patient safety experts and physicians raised concerns about the problem of preventable medical errors, which they say can be linked to more than 1,000 patient deaths per day.

For their part, SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, FHM, says hospitalists should demand that their hospitals report better data on patient outcomes.

"When you talk about a patient death, you're talking about the efforts of an entire hospital going into the death or survival of that patient," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York. "If you ask, 'Where did something go wrong?' just looking at the mortality rate doesn't help. What service are you inquiring about? How can you get clean data that’s also useful to the clinician?"

In his testimony before the Subcommittee on Primary Health and Aging, hospitalist Ashish Jha, MD, MPH, referenced a landmark 1999 report from the Institute of Medicine (IOM), "To Err Is Human: Building a Safer Health System," [PDF] which estimated that between 44,000 and 98,000 deaths in the U.S. each year can be attributed to preventable medical errors.

Since the IOM report was published, little has been done to change the systems of care delivery that can lead providers to make errors, said Dr. Jha, an internist at the VA Boston Healthcare System and professor of health policy and management at the Harvard School of Public Health in Boston.

"When a physician orders the wrong medication because two drugs might sound alike, or when a patient develops a central-line infection because a rushed surgeon didn't use proper sterile technique, we now understand that we need to focus on the system that produced the errors," Dr. Jha told Senate subcommittee members.

Both Dr. Jha and panelist Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, said the Centers for Disease Control and Prevention should expand its National Nosocomial Infections Surveillance Program to collect and report data on medical errors.

Several other speakers said hospitals should be mandated to publicly report medical errors.

"Public disclosure is a critical element to preventing these events from happening," said panelist Lisa McGiffert, director of the Consumers Union Safe Patient Project in Austin, Texas. "It informs people about healthcare outcomes and motivates healthcare providers to do more to prevent errors." TH

Visit our website for more information on the impact of medical errors.

Highlights from The Hospitalist this month include an interview with SHM President Dr. Burke Kealey about his series of President's Desk columns. Dr. Kealey talks about how the hospital medicine movement arose and expands on the transformational nature of hospital medicine. Also in this issue, we provide a comprehensive look at medical decision making, focused on the ins and outs of turning decisions into the right codes for billing and ongoing. Dr. Christopher Moreland, a deaf teaching hospitalist at University Hospital at the University of Texas is profiled on our cover, and Team Hospitalist member Dr. Julie Fedderson tells us what drew her to the specialty. In addition, we offer a progress report of SHM’s performance assessment tool for hospital medicine groups. Our Key Clinical Question this month addresses hypontremia treatment and managment, and our In The Literature section features the latest in clinical literature.

Click here to listen to the August highlights Podcast.

Highlights from The Hospitalist this month include an interview with SHM President Dr. Burke Kealey about his series of President's Desk columns. Dr. Kealey talks about how the hospital medicine movement arose and expands on the transformational nature of hospital medicine. Also in this issue, we provide a comprehensive look at medical decision making, focused on the ins and outs of turning decisions into the right codes for billing and ongoing. Dr. Christopher Moreland, a deaf teaching hospitalist at University Hospital at the University of Texas is profiled on our cover, and Team Hospitalist member Dr. Julie Fedderson tells us what drew her to the specialty. In addition, we offer a progress report of SHM’s performance assessment tool for hospital medicine groups. Our Key Clinical Question this month addresses hypontremia treatment and managment, and our In The Literature section features the latest in clinical literature.

Click here to listen to the August highlights Podcast.

Highlights from The Hospitalist this month include an interview with SHM President Dr. Burke Kealey about his series of President's Desk columns. Dr. Kealey talks about how the hospital medicine movement arose and expands on the transformational nature of hospital medicine. Also in this issue, we provide a comprehensive look at medical decision making, focused on the ins and outs of turning decisions into the right codes for billing and ongoing. Dr. Christopher Moreland, a deaf teaching hospitalist at University Hospital at the University of Texas is profiled on our cover, and Team Hospitalist member Dr. Julie Fedderson tells us what drew her to the specialty. In addition, we offer a progress report of SHM’s performance assessment tool for hospital medicine groups. Our Key Clinical Question this month addresses hypontremia treatment and managment, and our In The Literature section features the latest in clinical literature.

Click here to listen to the August highlights Podcast.

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Nurse practitioners and physician assistants are a critical part of the hospitalist care team. Together with the American Academy of Physician Assistants, SHM is hosting the annual Adult Hospital Medicine Boot Camp (www.aapa.org/bootcamp) specifically for nurse practitioners (NPs) and physician assistants (PAs).

The four-day program helps PAs and NPs stay up to date on the most common diagnoses, diseases, and treatments for hospitalized patients (27.75 hours Category 1 CME). A pre-course for PAs and NPs new to hospital medicine introduces them to the unique demands of inpatient care (eight hours Category 1 CME).

Adult Hospital Medicine Boot Camp October 2-5, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Hospital Medicine 101

October 1, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Nurse practitioners and physician assistants are a critical part of the hospitalist care team. Together with the American Academy of Physician Assistants, SHM is hosting the annual Adult Hospital Medicine Boot Camp (www.aapa.org/bootcamp) specifically for nurse practitioners (NPs) and physician assistants (PAs).

The four-day program helps PAs and NPs stay up to date on the most common diagnoses, diseases, and treatments for hospitalized patients (27.75 hours Category 1 CME). A pre-course for PAs and NPs new to hospital medicine introduces them to the unique demands of inpatient care (eight hours Category 1 CME).

Adult Hospital Medicine Boot Camp October 2-5, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Hospital Medicine 101

October 1, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Nurse practitioners and physician assistants are a critical part of the hospitalist care team. Together with the American Academy of Physician Assistants, SHM is hosting the annual Adult Hospital Medicine Boot Camp (www.aapa.org/bootcamp) specifically for nurse practitioners (NPs) and physician assistants (PAs).

The four-day program helps PAs and NPs stay up to date on the most common diagnoses, diseases, and treatments for hospitalized patients (27.75 hours Category 1 CME). A pre-course for PAs and NPs new to hospital medicine introduces them to the unique demands of inpatient care (eight hours Category 1 CME).

Adult Hospital Medicine Boot Camp October 2-5, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Hospital Medicine 101

October 1, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Recent meta-analysis that suggests aspirin might be as effective as some commonly used anticoagulants in preventing VTE following hip and knee replacement surgeries makes a case for further study, says a veteran hospitalist.

"Whereas we currently have a number of alternatives [at variable cost and efficacy] for preoperative prophylaxis against DVT and ensuing complications, we may be able to ultimately standardize a prophylactic regimen," Jairy C. Hunter, MD, MBA, SFHM, associate executive medical director for case management and care transitions at the Medical University of South Carolina in Charleston told The Hospitalist in an email. "If aspirin is found to be effective and safe as part of that regimen, then we can improve outcomes, as well as cost, while reducing the risk of complications from the prophylactic regimen itself."

Recently published in the Journal of Hospital Medicine, the paper reviewed eight randomized clinical trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity surgery (hip or knee replacement). Researchers' analysis included 1,408 participants and compared data on VTE, bleeding, and mortality risk with the type of medication involved.

The authors found aspirin to be as effective as anticoagulants for preventing VTE after lower extremity arthroplasty and linked it with lower bleeding risk after these surgeries. Aspirin also carried a lower risk of bleeding in patients following hip fracture repair, but researchers noted it might be linked with a higher risk of DVT in these patients, making anticoagulants a better choice for VTE prophylaxis post-hip fracture repair.

Frank Drescher, MD, assistant professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H., and lead author of the research, says he was surprised to see anticoagulants—often considered the stronger medication—made no difference compared with aspirin in lowering DVT risk with hip and knee replacement surgeries. He contends that patients' behavior post-surgery may make a difference.

Check out SHM's VTE prevention toolkit

"Early mobilization and pneumatic compression devices can help to prevent [VTE]," Dr. Dresher told The Hospitalist in an email. "It's possible that increasing use of non-pharmacological measures helps to mitigate differences between different pharmacological agents."

Hospitalists routinely see hip fracture repair patients and become involved in the orthopedic management of DVT prophylaxis, according to Anand Kartha, MD, MS, an academic hospitalist in the Veterans Affairs Boston Healthcare System and a member of Team Hospitalist. He says the research strengthens the idea "that physicians should not use aspirin on hip fracture patients for DVT prophylaxis or prevention" after surgery.

Dr. Drescher acknowledges some limitations of his meta-analysis, including the fact that researchers found few randomized trials with direct comparisons between aspirin and anticoagulants, and some trials were more than 10 years old. In the future, Dr. Drescher says he hopes to see more research on this topic.

Dr. Kartha agrees but says the first step is ensuring consistent use of the existing research. "Rather than debating the validity of one therapy versus the other…what is needed is consistent application of what is already known," he explains. "That is, there needs to be a standardized, institutional approach to this issue."TH

Visit our website for more information on VTE prophylaxis.

Recent meta-analysis that suggests aspirin might be as effective as some commonly used anticoagulants in preventing VTE following hip and knee replacement surgeries makes a case for further study, says a veteran hospitalist.

"Whereas we currently have a number of alternatives [at variable cost and efficacy] for preoperative prophylaxis against DVT and ensuing complications, we may be able to ultimately standardize a prophylactic regimen," Jairy C. Hunter, MD, MBA, SFHM, associate executive medical director for case management and care transitions at the Medical University of South Carolina in Charleston told The Hospitalist in an email. "If aspirin is found to be effective and safe as part of that regimen, then we can improve outcomes, as well as cost, while reducing the risk of complications from the prophylactic regimen itself."

Recently published in the Journal of Hospital Medicine, the paper reviewed eight randomized clinical trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity surgery (hip or knee replacement). Researchers' analysis included 1,408 participants and compared data on VTE, bleeding, and mortality risk with the type of medication involved.

The authors found aspirin to be as effective as anticoagulants for preventing VTE after lower extremity arthroplasty and linked it with lower bleeding risk after these surgeries. Aspirin also carried a lower risk of bleeding in patients following hip fracture repair, but researchers noted it might be linked with a higher risk of DVT in these patients, making anticoagulants a better choice for VTE prophylaxis post-hip fracture repair.

Frank Drescher, MD, assistant professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H., and lead author of the research, says he was surprised to see anticoagulants—often considered the stronger medication—made no difference compared with aspirin in lowering DVT risk with hip and knee replacement surgeries. He contends that patients' behavior post-surgery may make a difference.

Check out SHM's VTE prevention toolkit

"Early mobilization and pneumatic compression devices can help to prevent [VTE]," Dr. Dresher told The Hospitalist in an email. "It's possible that increasing use of non-pharmacological measures helps to mitigate differences between different pharmacological agents."

Hospitalists routinely see hip fracture repair patients and become involved in the orthopedic management of DVT prophylaxis, according to Anand Kartha, MD, MS, an academic hospitalist in the Veterans Affairs Boston Healthcare System and a member of Team Hospitalist. He says the research strengthens the idea "that physicians should not use aspirin on hip fracture patients for DVT prophylaxis or prevention" after surgery.

Dr. Drescher acknowledges some limitations of his meta-analysis, including the fact that researchers found few randomized trials with direct comparisons between aspirin and anticoagulants, and some trials were more than 10 years old. In the future, Dr. Drescher says he hopes to see more research on this topic.

Dr. Kartha agrees but says the first step is ensuring consistent use of the existing research. "Rather than debating the validity of one therapy versus the other…what is needed is consistent application of what is already known," he explains. "That is, there needs to be a standardized, institutional approach to this issue."TH

Visit our website for more information on VTE prophylaxis.

Recent meta-analysis that suggests aspirin might be as effective as some commonly used anticoagulants in preventing VTE following hip and knee replacement surgeries makes a case for further study, says a veteran hospitalist.

"Whereas we currently have a number of alternatives [at variable cost and efficacy] for preoperative prophylaxis against DVT and ensuing complications, we may be able to ultimately standardize a prophylactic regimen," Jairy C. Hunter, MD, MBA, SFHM, associate executive medical director for case management and care transitions at the Medical University of South Carolina in Charleston told The Hospitalist in an email. "If aspirin is found to be effective and safe as part of that regimen, then we can improve outcomes, as well as cost, while reducing the risk of complications from the prophylactic regimen itself."

Recently published in the Journal of Hospital Medicine, the paper reviewed eight randomized clinical trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity surgery (hip or knee replacement). Researchers' analysis included 1,408 participants and compared data on VTE, bleeding, and mortality risk with the type of medication involved.

The authors found aspirin to be as effective as anticoagulants for preventing VTE after lower extremity arthroplasty and linked it with lower bleeding risk after these surgeries. Aspirin also carried a lower risk of bleeding in patients following hip fracture repair, but researchers noted it might be linked with a higher risk of DVT in these patients, making anticoagulants a better choice for VTE prophylaxis post-hip fracture repair.

Frank Drescher, MD, assistant professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H., and lead author of the research, says he was surprised to see anticoagulants—often considered the stronger medication—made no difference compared with aspirin in lowering DVT risk with hip and knee replacement surgeries. He contends that patients' behavior post-surgery may make a difference.

Check out SHM's VTE prevention toolkit

"Early mobilization and pneumatic compression devices can help to prevent [VTE]," Dr. Dresher told The Hospitalist in an email. "It's possible that increasing use of non-pharmacological measures helps to mitigate differences between different pharmacological agents."

Hospitalists routinely see hip fracture repair patients and become involved in the orthopedic management of DVT prophylaxis, according to Anand Kartha, MD, MS, an academic hospitalist in the Veterans Affairs Boston Healthcare System and a member of Team Hospitalist. He says the research strengthens the idea "that physicians should not use aspirin on hip fracture patients for DVT prophylaxis or prevention" after surgery.

Dr. Drescher acknowledges some limitations of his meta-analysis, including the fact that researchers found few randomized trials with direct comparisons between aspirin and anticoagulants, and some trials were more than 10 years old. In the future, Dr. Drescher says he hopes to see more research on this topic.

Dr. Kartha agrees but says the first step is ensuring consistent use of the existing research. "Rather than debating the validity of one therapy versus the other…what is needed is consistent application of what is already known," he explains. "That is, there needs to be a standardized, institutional approach to this issue."TH

Visit our website for more information on VTE prophylaxis.

In March 2012, physicians and staff of the hospital medicine division at the University of California San Francisco (UCSF) kicked off a high-value care (HVC) program to more efficiently tie quality care delivery to healthcare costs. Early results suggest the plan is working, and the lead author of a recent paper believes other HM groups could use the program as a guide to implement similar plans in their own practices.

"There are a lot of idiosyncrasies between different programs and different medical centers, particularly when it comes to cost," says Christopher Moriates, MD, co-chair of the UCSF division's high-value care committee. "Many of the things we're identifying are indeed transplantable…but not all of them."

Published online this month in the Journal of Hospital Medicine, authors identify six ongoing HVC projects that have shown encouraging data in promoting improved healthcare value and clinician engagement. The projects are designed to:

• Reduce unnecessary nebulizer use;
• Curb overuse and inappropriate use of gastric stress ulcer prophylaxis;
• Encourage better blood utilization stewardship;
• Improve the use of telemetry;
• Scale back on inappropriate, repeat inpatient echocardiograms; and
• Reduce the number of ionized calcium labs.

To date, the nebulizer program has dropped usage rates by more than 50% on a high-acuity medical floor. Along with merely identifying waste-reduction and cost-savings plans, the program spells out goals for each initiative, strategies for reaching those goals, and next steps.

"We're not just creating these pilot programs and asking people to do more," Dr. Moriates says. "We're really thinking through these interventions as complete packages. We're really baking it into our culture. As we address what people actually do and change the systems around and change the way we think about things, it becomes standard practice and thus more likely to be sustainable." TH

Visit our website for more information on cost-effective, value-based patient care.

In March 2012, physicians and staff of the hospital medicine division at the University of California San Francisco (UCSF) kicked off a high-value care (HVC) program to more efficiently tie quality care delivery to healthcare costs. Early results suggest the plan is working, and the lead author of a recent paper believes other HM groups could use the program as a guide to implement similar plans in their own practices.

"There are a lot of idiosyncrasies between different programs and different medical centers, particularly when it comes to cost," says Christopher Moriates, MD, co-chair of the UCSF division's high-value care committee. "Many of the things we're identifying are indeed transplantable…but not all of them."

Published online this month in the Journal of Hospital Medicine, authors identify six ongoing HVC projects that have shown encouraging data in promoting improved healthcare value and clinician engagement. The projects are designed to:

• Reduce unnecessary nebulizer use;
• Curb overuse and inappropriate use of gastric stress ulcer prophylaxis;
• Encourage better blood utilization stewardship;
• Improve the use of telemetry;
• Scale back on inappropriate, repeat inpatient echocardiograms; and
• Reduce the number of ionized calcium labs.

To date, the nebulizer program has dropped usage rates by more than 50% on a high-acuity medical floor. Along with merely identifying waste-reduction and cost-savings plans, the program spells out goals for each initiative, strategies for reaching those goals, and next steps.

"We're not just creating these pilot programs and asking people to do more," Dr. Moriates says. "We're really thinking through these interventions as complete packages. We're really baking it into our culture. As we address what people actually do and change the systems around and change the way we think about things, it becomes standard practice and thus more likely to be sustainable." TH

Visit our website for more information on cost-effective, value-based patient care.

In March 2012, physicians and staff of the hospital medicine division at the University of California San Francisco (UCSF) kicked off a high-value care (HVC) program to more efficiently tie quality care delivery to healthcare costs. Early results suggest the plan is working, and the lead author of a recent paper believes other HM groups could use the program as a guide to implement similar plans in their own practices.

"There are a lot of idiosyncrasies between different programs and different medical centers, particularly when it comes to cost," says Christopher Moriates, MD, co-chair of the UCSF division's high-value care committee. "Many of the things we're identifying are indeed transplantable…but not all of them."

Published online this month in the Journal of Hospital Medicine, authors identify six ongoing HVC projects that have shown encouraging data in promoting improved healthcare value and clinician engagement. The projects are designed to:

• Reduce unnecessary nebulizer use;
• Curb overuse and inappropriate use of gastric stress ulcer prophylaxis;
• Encourage better blood utilization stewardship;
• Improve the use of telemetry;
• Scale back on inappropriate, repeat inpatient echocardiograms; and
• Reduce the number of ionized calcium labs.

To date, the nebulizer program has dropped usage rates by more than 50% on a high-acuity medical floor. Along with merely identifying waste-reduction and cost-savings plans, the program spells out goals for each initiative, strategies for reaching those goals, and next steps.

"We're not just creating these pilot programs and asking people to do more," Dr. Moriates says. "We're really thinking through these interventions as complete packages. We're really baking it into our culture. As we address what people actually do and change the systems around and change the way we think about things, it becomes standard practice and thus more likely to be sustainable." TH

Visit our website for more information on cost-effective, value-based patient care.

Presenters

--- Welcome Remarks: Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs, St. Louis Children’s Hospital

--- The Next Phase of Delivery System Reform: Patrick Conway, MD, MSc, FAAP, MHM, deputy administrator for innovation and quality, CMO for the Centers for Medicare & Medicaid Services (CMS)

--- Hospitals and Health Systems: What’s on the Mind of Your CEO?: David J. Bailey, MD, MBA, president and CEO, the Nemours Foundation; Steve Narang, MD, MHCM, CEO, Banner Good Samaritan Medical Center, Phoenix, Ariz.; Jeff Sperring, MD, FAAP, president and CEO, Riley Hospital for Children at Indiana University Health, Indianapolis.

Summary

PHM 2014 began to heat up in steamy Orlando, as Dr. Carlson, chair of the PHM 2014 Organizing Committee, welcomed more than 800 pediatric hospitalists at the four-day annual meeting dedicated to pediatric hospital medicine.

Dr. Conway, a pediatric hospitalist prior to joining CMS, updated the crowd of ongoing reforms in the U.S. healthcare delivery system, with a focus on pediatrics. Healthcare delivery, Dr. Conway asserted, needs to move from an unsustainable, volume-driven, fee-for-service system to a people-centered, sustainable system where payment can be shaped by value-based purchasing, ACO-shared savings, and episode-based payments.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement, and population health.”

As such, the six goals of the CMS Quality Strategy align well with ongoing PHM efforts:

• Make care safer by reducing harm caused in care delivery;
•  Strengthen patient and family engagement as partners in their care;
•  Promote effective communication and coordination of care;
•  Promote effective prevention and treatment of chronic disease;
•  Work with communities to promote healthy living; and
•  Make care affordable.

Citing Maryland as an example, where a plan is being considered to shift 80% of hospital revenues to global models by 2018, Dr. Conway painted a picture of a rapidly-shifting reimbursement landscape that will soon be dominated by value-based purchasing, penalties for readmissions and healthcare-acquired conditions, and increasing emphasis on bundled payments, ACOs, and primary care medical homes.

“Hospitals are getting paid to keep people out of the hospital,” he said, and concurrently per capita spending on healthcare is now at historic lows. While pediatric quality measures are not as mature as those for adult patients, many opportunities for increasing value in pediatric care have been developed, such as the Choosing Wisely campaign and the Value in Inpatient Pediatrics (VIP) network.

Although not restricted to pediatrics, the CMS Partnership for Patients also aims to have a major impact on child health. Goals of a 40% reduction in HACs and 20% reduction in preventable 30-day readmissions have been set by the Partnership, with specific focus on 10 core patient-safety areas. Preliminary data have been promising, with a 9% reduction in HACs between 2010 and 2012 across all measures.

“This is a historical reduction,” said Dr. Conway, representing more than 500,000 patient harm events avoided, over 15,000 lives saved, and more than $4 billion in cost savings.

Within pediatrics, a number of research efforts have added to this reduction, including the Pediatric Research in Inpatient Settings (PRIS) Network, PHIS+, I-PASS, as well as several collaborative improvement networks.

Looking to the future, Medicaid and Children’s Health Insurance Program will continue to focus on quality initiatives and system transformation. These will include developing more pediatric-focused quality measures, improving health information technology, and continuing to award innovation in pediatrics. Pediatrics will continue to be a leader in these efforts, Dr. Conway said, because “we should care about longer time horizons.”

Four healthcare system CEOs also took the stage to answer questions from the audience, with Mark Shen, MD, president of Dell Children’s Medical Center, posing questions like a seasoned talk-show host. Panel members fielded a wide range of questions, including:

— How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

— What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds…It depends on ACO penetration whether quality or volume will be the driver over the next 3-5 years,” Dr. Narang said.

“We have to create an accountable health community,” Dr. Shen said.

“The question is, how can you build a model that will allow you to flip the switch when this change occurs?” Dr. Sperring said.

— What is the role of hospitalists as care progresses from the most intensive but sometimes least appropriate site?

“I think the environment will drastically change, but there will be an ever enlarging role for hospitalists. … Hospitalists will likely be moving to LTACs, SNFs, even outpatient work.” Dr. Bailey said.

— If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. … I don’t think we’re going to be at a point where certification will limit being a hospitalist any time soon,” Dr. Shen said.

— How can we make health care pricing more transparent?

“Why is it that in other industries, things are getting cheaper and higher quality, but in healthcare we seem to be going in the opposite direction?” Dr. Bailey said. “There has to be transparency for the patient. How about transparency for the provider? Every EMR should have a price for everything your order.”

— What do you think we can do to get more women into executive roles?

“Based on the percentages of women in medical school, residencies, and fellowships, I think it is inevitable that women will be the future leaders for our system,” Dr. Sperring said.

— What are the three most important things from a CEO perspective that a hospitalist should know?

“You have to have self-awareness…as a leader, are you a listener, are you a delegator?” Dr. Bailey said.

“Know where your organization wants to go,” Dr. Sperring said.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Presenters

--- Welcome Remarks: Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs, St. Louis Children’s Hospital

--- The Next Phase of Delivery System Reform: Patrick Conway, MD, MSc, FAAP, MHM, deputy administrator for innovation and quality, CMO for the Centers for Medicare & Medicaid Services (CMS)

--- Hospitals and Health Systems: What’s on the Mind of Your CEO?: David J. Bailey, MD, MBA, president and CEO, the Nemours Foundation; Steve Narang, MD, MHCM, CEO, Banner Good Samaritan Medical Center, Phoenix, Ariz.; Jeff Sperring, MD, FAAP, president and CEO, Riley Hospital for Children at Indiana University Health, Indianapolis.

Summary

PHM 2014 began to heat up in steamy Orlando, as Dr. Carlson, chair of the PHM 2014 Organizing Committee, welcomed more than 800 pediatric hospitalists at the four-day annual meeting dedicated to pediatric hospital medicine.

Dr. Conway, a pediatric hospitalist prior to joining CMS, updated the crowd of ongoing reforms in the U.S. healthcare delivery system, with a focus on pediatrics. Healthcare delivery, Dr. Conway asserted, needs to move from an unsustainable, volume-driven, fee-for-service system to a people-centered, sustainable system where payment can be shaped by value-based purchasing, ACO-shared savings, and episode-based payments.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement, and population health.”

As such, the six goals of the CMS Quality Strategy align well with ongoing PHM efforts:

• Make care safer by reducing harm caused in care delivery;
•  Strengthen patient and family engagement as partners in their care;
•  Promote effective communication and coordination of care;
•  Promote effective prevention and treatment of chronic disease;
•  Work with communities to promote healthy living; and
•  Make care affordable.

Citing Maryland as an example, where a plan is being considered to shift 80% of hospital revenues to global models by 2018, Dr. Conway painted a picture of a rapidly-shifting reimbursement landscape that will soon be dominated by value-based purchasing, penalties for readmissions and healthcare-acquired conditions, and increasing emphasis on bundled payments, ACOs, and primary care medical homes.

“Hospitals are getting paid to keep people out of the hospital,” he said, and concurrently per capita spending on healthcare is now at historic lows. While pediatric quality measures are not as mature as those for adult patients, many opportunities for increasing value in pediatric care have been developed, such as the Choosing Wisely campaign and the Value in Inpatient Pediatrics (VIP) network.

Although not restricted to pediatrics, the CMS Partnership for Patients also aims to have a major impact on child health. Goals of a 40% reduction in HACs and 20% reduction in preventable 30-day readmissions have been set by the Partnership, with specific focus on 10 core patient-safety areas. Preliminary data have been promising, with a 9% reduction in HACs between 2010 and 2012 across all measures.

“This is a historical reduction,” said Dr. Conway, representing more than 500,000 patient harm events avoided, over 15,000 lives saved, and more than $4 billion in cost savings.

Within pediatrics, a number of research efforts have added to this reduction, including the Pediatric Research in Inpatient Settings (PRIS) Network, PHIS+, I-PASS, as well as several collaborative improvement networks.

Looking to the future, Medicaid and Children’s Health Insurance Program will continue to focus on quality initiatives and system transformation. These will include developing more pediatric-focused quality measures, improving health information technology, and continuing to award innovation in pediatrics. Pediatrics will continue to be a leader in these efforts, Dr. Conway said, because “we should care about longer time horizons.”

Four healthcare system CEOs also took the stage to answer questions from the audience, with Mark Shen, MD, president of Dell Children’s Medical Center, posing questions like a seasoned talk-show host. Panel members fielded a wide range of questions, including:

— How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

— What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds…It depends on ACO penetration whether quality or volume will be the driver over the next 3-5 years,” Dr. Narang said.

“We have to create an accountable health community,” Dr. Shen said.

“The question is, how can you build a model that will allow you to flip the switch when this change occurs?” Dr. Sperring said.

— What is the role of hospitalists as care progresses from the most intensive but sometimes least appropriate site?

“I think the environment will drastically change, but there will be an ever enlarging role for hospitalists. … Hospitalists will likely be moving to LTACs, SNFs, even outpatient work.” Dr. Bailey said.

— If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. … I don’t think we’re going to be at a point where certification will limit being a hospitalist any time soon,” Dr. Shen said.

— How can we make health care pricing more transparent?

“Why is it that in other industries, things are getting cheaper and higher quality, but in healthcare we seem to be going in the opposite direction?” Dr. Bailey said. “There has to be transparency for the patient. How about transparency for the provider? Every EMR should have a price for everything your order.”

— What do you think we can do to get more women into executive roles?

“Based on the percentages of women in medical school, residencies, and fellowships, I think it is inevitable that women will be the future leaders for our system,” Dr. Sperring said.

— What are the three most important things from a CEO perspective that a hospitalist should know?

“You have to have self-awareness…as a leader, are you a listener, are you a delegator?” Dr. Bailey said.

“Know where your organization wants to go,” Dr. Sperring said.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Presenters

--- Welcome Remarks: Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs, St. Louis Children’s Hospital

--- The Next Phase of Delivery System Reform: Patrick Conway, MD, MSc, FAAP, MHM, deputy administrator for innovation and quality, CMO for the Centers for Medicare & Medicaid Services (CMS)

--- Hospitals and Health Systems: What’s on the Mind of Your CEO?: David J. Bailey, MD, MBA, president and CEO, the Nemours Foundation; Steve Narang, MD, MHCM, CEO, Banner Good Samaritan Medical Center, Phoenix, Ariz.; Jeff Sperring, MD, FAAP, president and CEO, Riley Hospital for Children at Indiana University Health, Indianapolis.

Summary

PHM 2014 began to heat up in steamy Orlando, as Dr. Carlson, chair of the PHM 2014 Organizing Committee, welcomed more than 800 pediatric hospitalists at the four-day annual meeting dedicated to pediatric hospital medicine.

Dr. Conway, a pediatric hospitalist prior to joining CMS, updated the crowd of ongoing reforms in the U.S. healthcare delivery system, with a focus on pediatrics. Healthcare delivery, Dr. Conway asserted, needs to move from an unsustainable, volume-driven, fee-for-service system to a people-centered, sustainable system where payment can be shaped by value-based purchasing, ACO-shared savings, and episode-based payments.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement, and population health.”

As such, the six goals of the CMS Quality Strategy align well with ongoing PHM efforts:

• Make care safer by reducing harm caused in care delivery;
•  Strengthen patient and family engagement as partners in their care;
•  Promote effective communication and coordination of care;
•  Promote effective prevention and treatment of chronic disease;
•  Work with communities to promote healthy living; and
•  Make care affordable.

Citing Maryland as an example, where a plan is being considered to shift 80% of hospital revenues to global models by 2018, Dr. Conway painted a picture of a rapidly-shifting reimbursement landscape that will soon be dominated by value-based purchasing, penalties for readmissions and healthcare-acquired conditions, and increasing emphasis on bundled payments, ACOs, and primary care medical homes.

“Hospitals are getting paid to keep people out of the hospital,” he said, and concurrently per capita spending on healthcare is now at historic lows. While pediatric quality measures are not as mature as those for adult patients, many opportunities for increasing value in pediatric care have been developed, such as the Choosing Wisely campaign and the Value in Inpatient Pediatrics (VIP) network.

Although not restricted to pediatrics, the CMS Partnership for Patients also aims to have a major impact on child health. Goals of a 40% reduction in HACs and 20% reduction in preventable 30-day readmissions have been set by the Partnership, with specific focus on 10 core patient-safety areas. Preliminary data have been promising, with a 9% reduction in HACs between 2010 and 2012 across all measures.

“This is a historical reduction,” said Dr. Conway, representing more than 500,000 patient harm events avoided, over 15,000 lives saved, and more than $4 billion in cost savings.

Within pediatrics, a number of research efforts have added to this reduction, including the Pediatric Research in Inpatient Settings (PRIS) Network, PHIS+, I-PASS, as well as several collaborative improvement networks.

Looking to the future, Medicaid and Children’s Health Insurance Program will continue to focus on quality initiatives and system transformation. These will include developing more pediatric-focused quality measures, improving health information technology, and continuing to award innovation in pediatrics. Pediatrics will continue to be a leader in these efforts, Dr. Conway said, because “we should care about longer time horizons.”

Four healthcare system CEOs also took the stage to answer questions from the audience, with Mark Shen, MD, president of Dell Children’s Medical Center, posing questions like a seasoned talk-show host. Panel members fielded a wide range of questions, including:

— How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

— What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds…It depends on ACO penetration whether quality or volume will be the driver over the next 3-5 years,” Dr. Narang said.

“We have to create an accountable health community,” Dr. Shen said.

“The question is, how can you build a model that will allow you to flip the switch when this change occurs?” Dr. Sperring said.

— What is the role of hospitalists as care progresses from the most intensive but sometimes least appropriate site?

“I think the environment will drastically change, but there will be an ever enlarging role for hospitalists. … Hospitalists will likely be moving to LTACs, SNFs, even outpatient work.” Dr. Bailey said.

— If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. … I don’t think we’re going to be at a point where certification will limit being a hospitalist any time soon,” Dr. Shen said.

— How can we make health care pricing more transparent?

“Why is it that in other industries, things are getting cheaper and higher quality, but in healthcare we seem to be going in the opposite direction?” Dr. Bailey said. “There has to be transparency for the patient. How about transparency for the provider? Every EMR should have a price for everything your order.”

— What do you think we can do to get more women into executive roles?

“Based on the percentages of women in medical school, residencies, and fellowships, I think it is inevitable that women will be the future leaders for our system,” Dr. Sperring said.

— What are the three most important things from a CEO perspective that a hospitalist should know?

“You have to have self-awareness…as a leader, are you a listener, are you a delegator?” Dr. Bailey said.

“Know where your organization wants to go,” Dr. Sperring said.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.