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Being in stressful situations is part of being a hospitalist. During a hospitalist’s work shift, one of the key determinants of stress is adequate staffing. With use of survey data from 569 hospital medicine groups (HMGs) across the nation, one of the topics examined in the 2018 State of Hospital Medicine Report is how HMGs cope with unfilled hospitalist physician positions.

The survey presented five options for covering unfilled hospitalist physician positions: use of locum tenens, use of moonlighters, use of voluntary extra shifts by the HMG’s existing hospitalists, use of required extra shifts, and leaving some shifts uncovered. Recipients were instructed to select all options that applied, so totals exceeded 100%. The data is organized according to HMGs that serve adults only, children only, and both adults and children.

For all three types of HMGs, the most common tactic to fill coverage gaps is through voluntary extra shifts by existing clinicians, reportedly used by 70.3% of HMGs that cover adults only, 66.7% by those that cover children only, and 76.9% by those that cover both adults and children. Data for adults-only HMGs was further broken down by geographic region, academic status, teaching status, group size, and employment model. Among adults-only HMGs, there is a direct correlation between group size and having members voluntarily work extra shifts, with 91.1% of groups with 30 or more full-time equivalent positions employing this tactic.

For HMGs that cover adults only and those that cover children only, the second most common tactic is to use moonlighters (57.4% and 53.3% respectively), while use of moonlighters is the third most commonly employed surveyed tactic for HMGs that cover both adults and children (53.8%).

HMGs that serve both adults and children were much more likely to utilize locum tenens to cover unfilled positions (69.2%) than were groups that serve adults only (44.0%) or children only (26.7%). The variability in the use of locum tenens is likely because of the willingness and/or ability of the respective groups to afford this option because it is generally the most expensive option of those surveyed.

Requiring that members of the group work extra shifts is the least popular staffing method among adults-only HMGs (10.0%) and HMGs serving both children and adults (7.7%). This strategy is unpopular, especially when there is little advance warning. Surprisingly, 40.0% of HMGs that see children only require members to work extra shifts to cover unfilled slots. This could be because pediatric HMGs are often smaller, and it would be more difficult to absorb the work if the shift is left uncovered. In fact, many pediatric HMGs staff with only one clinician at a time, so there may be no option besides requiring someone else in the group to come in and work.Of the options surveyed, perhaps the most uncomfortable for those hospitalist physicians on duty is to leave some shifts uncovered. The rapid growth and development of the specialty of hospital medicine has made it difficult for HMGs to continuously hire qualified hospitalists fast enough to meet demand. The survey found 46.2% of HMGs that serve both adults and children and 31.4% of groups that serve adults only have employed the staffing model of going short-staffed for at least some shifts. HMGs serving children-only are much less likely to go short-staffed (20.0%).

I work with a large HMG that has more than 70 members, and when it has been short-staffed, it tries to ensure a full complement of evening and night staff as the top priority because these shifts are typically more stressful. Since we have more hospitalist capacity during the day to absorb the loss of a physician, we pull staff from their daytime rounding schedules to execute this strategy. While going short-staffed is not ideal, this option has worked for many groups out of sheer necessity.

Dr. Stephan is a hospitalist at Allina Health’s Abbott Northwestern Hospital in Minneapolis and is a member of the SHM Practice Analysis Committee.

Being in stressful situations is part of being a hospitalist. During a hospitalist’s work shift, one of the key determinants of stress is adequate staffing. With use of survey data from 569 hospital medicine groups (HMGs) across the nation, one of the topics examined in the 2018 State of Hospital Medicine Report is how HMGs cope with unfilled hospitalist physician positions.

The survey presented five options for covering unfilled hospitalist physician positions: use of locum tenens, use of moonlighters, use of voluntary extra shifts by the HMG’s existing hospitalists, use of required extra shifts, and leaving some shifts uncovered. Recipients were instructed to select all options that applied, so totals exceeded 100%. The data is organized according to HMGs that serve adults only, children only, and both adults and children.

For all three types of HMGs, the most common tactic to fill coverage gaps is through voluntary extra shifts by existing clinicians, reportedly used by 70.3% of HMGs that cover adults only, 66.7% by those that cover children only, and 76.9% by those that cover both adults and children. Data for adults-only HMGs was further broken down by geographic region, academic status, teaching status, group size, and employment model. Among adults-only HMGs, there is a direct correlation between group size and having members voluntarily work extra shifts, with 91.1% of groups with 30 or more full-time equivalent positions employing this tactic.

For HMGs that cover adults only and those that cover children only, the second most common tactic is to use moonlighters (57.4% and 53.3% respectively), while use of moonlighters is the third most commonly employed surveyed tactic for HMGs that cover both adults and children (53.8%).

HMGs that serve both adults and children were much more likely to utilize locum tenens to cover unfilled positions (69.2%) than were groups that serve adults only (44.0%) or children only (26.7%). The variability in the use of locum tenens is likely because of the willingness and/or ability of the respective groups to afford this option because it is generally the most expensive option of those surveyed.

Requiring that members of the group work extra shifts is the least popular staffing method among adults-only HMGs (10.0%) and HMGs serving both children and adults (7.7%). This strategy is unpopular, especially when there is little advance warning. Surprisingly, 40.0% of HMGs that see children only require members to work extra shifts to cover unfilled slots. This could be because pediatric HMGs are often smaller, and it would be more difficult to absorb the work if the shift is left uncovered. In fact, many pediatric HMGs staff with only one clinician at a time, so there may be no option besides requiring someone else in the group to come in and work.Of the options surveyed, perhaps the most uncomfortable for those hospitalist physicians on duty is to leave some shifts uncovered. The rapid growth and development of the specialty of hospital medicine has made it difficult for HMGs to continuously hire qualified hospitalists fast enough to meet demand. The survey found 46.2% of HMGs that serve both adults and children and 31.4% of groups that serve adults only have employed the staffing model of going short-staffed for at least some shifts. HMGs serving children-only are much less likely to go short-staffed (20.0%).

I work with a large HMG that has more than 70 members, and when it has been short-staffed, it tries to ensure a full complement of evening and night staff as the top priority because these shifts are typically more stressful. Since we have more hospitalist capacity during the day to absorb the loss of a physician, we pull staff from their daytime rounding schedules to execute this strategy. While going short-staffed is not ideal, this option has worked for many groups out of sheer necessity.

Dr. Stephan is a hospitalist at Allina Health’s Abbott Northwestern Hospital in Minneapolis and is a member of the SHM Practice Analysis Committee.

Being in stressful situations is part of being a hospitalist. During a hospitalist’s work shift, one of the key determinants of stress is adequate staffing. With use of survey data from 569 hospital medicine groups (HMGs) across the nation, one of the topics examined in the 2018 State of Hospital Medicine Report is how HMGs cope with unfilled hospitalist physician positions.

The survey presented five options for covering unfilled hospitalist physician positions: use of locum tenens, use of moonlighters, use of voluntary extra shifts by the HMG’s existing hospitalists, use of required extra shifts, and leaving some shifts uncovered. Recipients were instructed to select all options that applied, so totals exceeded 100%. The data is organized according to HMGs that serve adults only, children only, and both adults and children.

For all three types of HMGs, the most common tactic to fill coverage gaps is through voluntary extra shifts by existing clinicians, reportedly used by 70.3% of HMGs that cover adults only, 66.7% by those that cover children only, and 76.9% by those that cover both adults and children. Data for adults-only HMGs was further broken down by geographic region, academic status, teaching status, group size, and employment model. Among adults-only HMGs, there is a direct correlation between group size and having members voluntarily work extra shifts, with 91.1% of groups with 30 or more full-time equivalent positions employing this tactic.

For HMGs that cover adults only and those that cover children only, the second most common tactic is to use moonlighters (57.4% and 53.3% respectively), while use of moonlighters is the third most commonly employed surveyed tactic for HMGs that cover both adults and children (53.8%).

HMGs that serve both adults and children were much more likely to utilize locum tenens to cover unfilled positions (69.2%) than were groups that serve adults only (44.0%) or children only (26.7%). The variability in the use of locum tenens is likely because of the willingness and/or ability of the respective groups to afford this option because it is generally the most expensive option of those surveyed.

Requiring that members of the group work extra shifts is the least popular staffing method among adults-only HMGs (10.0%) and HMGs serving both children and adults (7.7%). This strategy is unpopular, especially when there is little advance warning. Surprisingly, 40.0% of HMGs that see children only require members to work extra shifts to cover unfilled slots. This could be because pediatric HMGs are often smaller, and it would be more difficult to absorb the work if the shift is left uncovered. In fact, many pediatric HMGs staff with only one clinician at a time, so there may be no option besides requiring someone else in the group to come in and work.Of the options surveyed, perhaps the most uncomfortable for those hospitalist physicians on duty is to leave some shifts uncovered. The rapid growth and development of the specialty of hospital medicine has made it difficult for HMGs to continuously hire qualified hospitalists fast enough to meet demand. The survey found 46.2% of HMGs that serve both adults and children and 31.4% of groups that serve adults only have employed the staffing model of going short-staffed for at least some shifts. HMGs serving children-only are much less likely to go short-staffed (20.0%).

I work with a large HMG that has more than 70 members, and when it has been short-staffed, it tries to ensure a full complement of evening and night staff as the top priority because these shifts are typically more stressful. Since we have more hospitalist capacity during the day to absorb the loss of a physician, we pull staff from their daytime rounding schedules to execute this strategy. While going short-staffed is not ideal, this option has worked for many groups out of sheer necessity.

Dr. Stephan is a hospitalist at Allina Health’s Abbott Northwestern Hospital in Minneapolis and is a member of the SHM Practice Analysis Committee.

Christopher Moriates, MD, has been named executive director of the nonprofit health care organization Costs of Care (Boston). He replaces Neel Shah, MD, who was tabbed chairperson of the board.

Dr. Moriates serves a number of roles at the University of Texas at Austin. He is the assistant dean for health care value; associate chair for quality, safety and value; and associate professor of internal medicine.

In his role at Costs of Care, Dr. Moriates will direct an organization that uses feedback and stories from frontline physicians to help health systems provide high-quality care at lower costs.

Kai Mebust, MD, was recently named the new associate chief of medicine at Bassett Hospital (Cooperstown, N.Y.), where he has worked the past 15 years as a hospitalist and internist, serving as chief of hospitalists for the last decade. Dr. Mebust also completed his internship and residency at Bassett, and he is a fellow with the Society of Hospital Medicine.

Dr. Mebust will work closely with Dr. Charles Hyman, the center’s physician in chief, who is leaving the role at the end of the calendar year. Dr. Mebust will oversee inpatient services and be part of the transition process when Dr. Hyman departs.

Ronak Bhimani, MD, has been appointed chief medical officer at Lower Bucks Hospital (Bristol, Pa.). Dr. Bhimani moves over from Suburban Community Hospital (Norristown, Pa.), where he served as an academic hospitalist the past 2 years.

Previously, Dr. Bhimani was medical director of Kindred/Avalon Hospice and a core faculty member in the internal medicine program for residents at Suburban Community.

Danielle Prince, MD, was recently named associate medical director at St. Luke’s Siouxland PACE (Sioux City, Iowa), an affiliate of UnityPoint Health. Dr. Prince is a practicing hospitalist at UnityPoint Health St. Luke’s and served previously in as a family physician while working as chief medical informatics officer at Mercy Medical Center (Sioux City).

At Siouxland PACE, Dr. Prince will assist in managing the full-service care of elderly patients, including home health, specialty care, medications, transportation, and other therapies.

Alex Rankin, MD, has been named the new associate chief medical officer for the University of New Mexico Health Transfer Center and Patient Throughput in Albuquerque. A hospitalist with UNMH’s Family and Community Medicine department, Dr. Rankin was previously the medical director at the system’s 3 North facility since 2014.

Dr. Rankin came to UNMH after working for hospitals in Colorado and Nebraska and is a founding member of the UNMH patient flow committee, striving to improve patient care processes throughout the institution.

Tom Guirkin, MD, has been appointed vice president of medical affairs for Virginia Commonwealth University Community Memorial Hospital (South Hill, Va.). Dr. Guirkin, a Virginia native, returns to his home state after most recently overseeing the hospitalist group at Saint Francis Health System (Tulsa, Okla.).

Dr. Guirkin will have the opportunity to continue practicing medicine at CMH while helping to manage the quality management side of the business. He received his MBA from Virginia Commonwealth, working for James River Hospitalist Group in Richmond at the same time.

Alteon Health (Germantown, Md.) has become the manager of hospitalist services for three facilities in Maryland and Ohio, including Carroll Hospital (Westminster, Md.), Washington Adventist Hospital (Takoma Park, Md.), and University Hospitals Cleveland Medical Center.

At Carroll, Alteon physicians will provide critical care services in addition to hospitalist duties. Alteon has been Carroll’s emergency medicine provider for more than two decades.

At Washington Adventist, Alteon will take over the hospitalist program, adding to the emergency medicine services it has provided since 1991 and critical care services it has managed since 1996.

At UH Cleveland, Alteon will assume hospitalist management at its third University Hospitals facility. Alteon controls emergency medicine at 14 UH locations as well. UH Cleveland is an affiliate of Case Western Reserve University.

Christopher Moriates, MD, has been named executive director of the nonprofit health care organization Costs of Care (Boston). He replaces Neel Shah, MD, who was tabbed chairperson of the board.

Dr. Moriates serves a number of roles at the University of Texas at Austin. He is the assistant dean for health care value; associate chair for quality, safety and value; and associate professor of internal medicine.

In his role at Costs of Care, Dr. Moriates will direct an organization that uses feedback and stories from frontline physicians to help health systems provide high-quality care at lower costs.

Kai Mebust, MD, was recently named the new associate chief of medicine at Bassett Hospital (Cooperstown, N.Y.), where he has worked the past 15 years as a hospitalist and internist, serving as chief of hospitalists for the last decade. Dr. Mebust also completed his internship and residency at Bassett, and he is a fellow with the Society of Hospital Medicine.

Dr. Mebust will work closely with Dr. Charles Hyman, the center’s physician in chief, who is leaving the role at the end of the calendar year. Dr. Mebust will oversee inpatient services and be part of the transition process when Dr. Hyman departs.

Ronak Bhimani, MD, has been appointed chief medical officer at Lower Bucks Hospital (Bristol, Pa.). Dr. Bhimani moves over from Suburban Community Hospital (Norristown, Pa.), where he served as an academic hospitalist the past 2 years.

Previously, Dr. Bhimani was medical director of Kindred/Avalon Hospice and a core faculty member in the internal medicine program for residents at Suburban Community.

Danielle Prince, MD, was recently named associate medical director at St. Luke’s Siouxland PACE (Sioux City, Iowa), an affiliate of UnityPoint Health. Dr. Prince is a practicing hospitalist at UnityPoint Health St. Luke’s and served previously in as a family physician while working as chief medical informatics officer at Mercy Medical Center (Sioux City).

At Siouxland PACE, Dr. Prince will assist in managing the full-service care of elderly patients, including home health, specialty care, medications, transportation, and other therapies.

Alex Rankin, MD, has been named the new associate chief medical officer for the University of New Mexico Health Transfer Center and Patient Throughput in Albuquerque. A hospitalist with UNMH’s Family and Community Medicine department, Dr. Rankin was previously the medical director at the system’s 3 North facility since 2014.

Dr. Rankin came to UNMH after working for hospitals in Colorado and Nebraska and is a founding member of the UNMH patient flow committee, striving to improve patient care processes throughout the institution.

Tom Guirkin, MD, has been appointed vice president of medical affairs for Virginia Commonwealth University Community Memorial Hospital (South Hill, Va.). Dr. Guirkin, a Virginia native, returns to his home state after most recently overseeing the hospitalist group at Saint Francis Health System (Tulsa, Okla.).

Dr. Guirkin will have the opportunity to continue practicing medicine at CMH while helping to manage the quality management side of the business. He received his MBA from Virginia Commonwealth, working for James River Hospitalist Group in Richmond at the same time.

Alteon Health (Germantown, Md.) has become the manager of hospitalist services for three facilities in Maryland and Ohio, including Carroll Hospital (Westminster, Md.), Washington Adventist Hospital (Takoma Park, Md.), and University Hospitals Cleveland Medical Center.

At Carroll, Alteon physicians will provide critical care services in addition to hospitalist duties. Alteon has been Carroll’s emergency medicine provider for more than two decades.

At Washington Adventist, Alteon will take over the hospitalist program, adding to the emergency medicine services it has provided since 1991 and critical care services it has managed since 1996.

At UH Cleveland, Alteon will assume hospitalist management at its third University Hospitals facility. Alteon controls emergency medicine at 14 UH locations as well. UH Cleveland is an affiliate of Case Western Reserve University.

Christopher Moriates, MD, has been named executive director of the nonprofit health care organization Costs of Care (Boston). He replaces Neel Shah, MD, who was tabbed chairperson of the board.

Dr. Moriates serves a number of roles at the University of Texas at Austin. He is the assistant dean for health care value; associate chair for quality, safety and value; and associate professor of internal medicine.

In his role at Costs of Care, Dr. Moriates will direct an organization that uses feedback and stories from frontline physicians to help health systems provide high-quality care at lower costs.

Kai Mebust, MD, was recently named the new associate chief of medicine at Bassett Hospital (Cooperstown, N.Y.), where he has worked the past 15 years as a hospitalist and internist, serving as chief of hospitalists for the last decade. Dr. Mebust also completed his internship and residency at Bassett, and he is a fellow with the Society of Hospital Medicine.

Dr. Mebust will work closely with Dr. Charles Hyman, the center’s physician in chief, who is leaving the role at the end of the calendar year. Dr. Mebust will oversee inpatient services and be part of the transition process when Dr. Hyman departs.

Ronak Bhimani, MD, has been appointed chief medical officer at Lower Bucks Hospital (Bristol, Pa.). Dr. Bhimani moves over from Suburban Community Hospital (Norristown, Pa.), where he served as an academic hospitalist the past 2 years.

Previously, Dr. Bhimani was medical director of Kindred/Avalon Hospice and a core faculty member in the internal medicine program for residents at Suburban Community.

Danielle Prince, MD, was recently named associate medical director at St. Luke’s Siouxland PACE (Sioux City, Iowa), an affiliate of UnityPoint Health. Dr. Prince is a practicing hospitalist at UnityPoint Health St. Luke’s and served previously in as a family physician while working as chief medical informatics officer at Mercy Medical Center (Sioux City).

At Siouxland PACE, Dr. Prince will assist in managing the full-service care of elderly patients, including home health, specialty care, medications, transportation, and other therapies.

Alex Rankin, MD, has been named the new associate chief medical officer for the University of New Mexico Health Transfer Center and Patient Throughput in Albuquerque. A hospitalist with UNMH’s Family and Community Medicine department, Dr. Rankin was previously the medical director at the system’s 3 North facility since 2014.

Dr. Rankin came to UNMH after working for hospitals in Colorado and Nebraska and is a founding member of the UNMH patient flow committee, striving to improve patient care processes throughout the institution.

Tom Guirkin, MD, has been appointed vice president of medical affairs for Virginia Commonwealth University Community Memorial Hospital (South Hill, Va.). Dr. Guirkin, a Virginia native, returns to his home state after most recently overseeing the hospitalist group at Saint Francis Health System (Tulsa, Okla.).

Dr. Guirkin will have the opportunity to continue practicing medicine at CMH while helping to manage the quality management side of the business. He received his MBA from Virginia Commonwealth, working for James River Hospitalist Group in Richmond at the same time.

Alteon Health (Germantown, Md.) has become the manager of hospitalist services for three facilities in Maryland and Ohio, including Carroll Hospital (Westminster, Md.), Washington Adventist Hospital (Takoma Park, Md.), and University Hospitals Cleveland Medical Center.

At Carroll, Alteon physicians will provide critical care services in addition to hospitalist duties. Alteon has been Carroll’s emergency medicine provider for more than two decades.

At Washington Adventist, Alteon will take over the hospitalist program, adding to the emergency medicine services it has provided since 1991 and critical care services it has managed since 1996.

At UH Cleveland, Alteon will assume hospitalist management at its third University Hospitals facility. Alteon controls emergency medicine at 14 UH locations as well. UH Cleveland is an affiliate of Case Western Reserve University.

Two-thirds of patients hospitalized with pneumonia received an excess duration of antibiotics, according to a recent study of more than 6,000 patients.

Longer antibiotic courses did not increase the survival rate or prevent any subsequent health care utilization, authors said; instead, they increased the risk of patient-reported adverse events.

The findings bolster a growing body of evidence showing that short-course therapy for pneumonia is safe and that longer durations are not only unnecessary, but “potentially harmful,” said Valerie M. Vaughn, MD, assistant professor of medicine at the University of Michigan, Ann Arbor, and coinvestigators.

“Reducing excess treatment durations should be a top priority for antibiotic stewardship nationally,” the investigators wrote in their report, which appears in the Annals of Internal Medicine.

The primary analysis of their retrospective cohort study included 6,481 individuals with pneumonia treated at 43 hospitals participating in a statewide quality initiative designed to improve care for hospitalized medical patients at risk of adverse events. About half of the patients were women, and the median age was 70 years. Nearly 60% had severe pneumonia.

The primary outcome of the study was the rate of excess antibiotic therapy duration beyond the shortest expected treatment duration consistent with guidelines. Patients with community-acquired pneumonia (CAP), representing about three-quarters of the study cohort, were expected to have a treatment duration of at least 5 days, while patients with health care–acquired pneumonia (HCAP) were expected to have at least 7 days of treatment.

Overall, 4,391 patients (67.8%) had antibiotic courses longer than the shortest effective duration, with a median duration of 8 days, and a median excess duration of 2 days, the researchers noted.

The great majority of excess days (93.2%) were due to antibiotic prescribed at discharge, according to Dr. Vaughn and colleagues.

Excess treatment duration was not linked to any improvement in 30-day mortality, readmission rates, or subsequent emergency department visits, they found.

In a telephone call at 30 days, 38% of patients treated to excess said they had gone to the doctor for an antibiotic-associated adverse event, compared with 31% who received appropriate-length courses (P = .003).

Odds of a patient-reported adverse event were increased by 5% for every excess treatment day, the investigators wrote.

Taken together, these findings have implications for patient care, research efforts, and future guidelines, according to Dr. Vaughn and coinvestigators.

“The next iteration of CAP and HCAP guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration,” they said in a discussion of their study results.

Dr. Vaughn reported no disclosures related to the study. Coauthors reported grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, personal fees from Wiley Publishing, and royalties from Wolters Kluwer Publishing and Oxford University Press, among other disclosures.

SOURCE: Vaughn VM et al. Ann Intern Med. 2019;171:153-63. doi: 10.7326/M18-3640.

Two-thirds of patients hospitalized with pneumonia received an excess duration of antibiotics, according to a recent study of more than 6,000 patients.

Longer antibiotic courses did not increase the survival rate or prevent any subsequent health care utilization, authors said; instead, they increased the risk of patient-reported adverse events.

The findings bolster a growing body of evidence showing that short-course therapy for pneumonia is safe and that longer durations are not only unnecessary, but “potentially harmful,” said Valerie M. Vaughn, MD, assistant professor of medicine at the University of Michigan, Ann Arbor, and coinvestigators.

“Reducing excess treatment durations should be a top priority for antibiotic stewardship nationally,” the investigators wrote in their report, which appears in the Annals of Internal Medicine.

The primary analysis of their retrospective cohort study included 6,481 individuals with pneumonia treated at 43 hospitals participating in a statewide quality initiative designed to improve care for hospitalized medical patients at risk of adverse events. About half of the patients were women, and the median age was 70 years. Nearly 60% had severe pneumonia.

The primary outcome of the study was the rate of excess antibiotic therapy duration beyond the shortest expected treatment duration consistent with guidelines. Patients with community-acquired pneumonia (CAP), representing about three-quarters of the study cohort, were expected to have a treatment duration of at least 5 days, while patients with health care–acquired pneumonia (HCAP) were expected to have at least 7 days of treatment.

Overall, 4,391 patients (67.8%) had antibiotic courses longer than the shortest effective duration, with a median duration of 8 days, and a median excess duration of 2 days, the researchers noted.

The great majority of excess days (93.2%) were due to antibiotic prescribed at discharge, according to Dr. Vaughn and colleagues.

Excess treatment duration was not linked to any improvement in 30-day mortality, readmission rates, or subsequent emergency department visits, they found.

In a telephone call at 30 days, 38% of patients treated to excess said they had gone to the doctor for an antibiotic-associated adverse event, compared with 31% who received appropriate-length courses (P = .003).

Odds of a patient-reported adverse event were increased by 5% for every excess treatment day, the investigators wrote.

Taken together, these findings have implications for patient care, research efforts, and future guidelines, according to Dr. Vaughn and coinvestigators.

“The next iteration of CAP and HCAP guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration,” they said in a discussion of their study results.

Dr. Vaughn reported no disclosures related to the study. Coauthors reported grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, personal fees from Wiley Publishing, and royalties from Wolters Kluwer Publishing and Oxford University Press, among other disclosures.

SOURCE: Vaughn VM et al. Ann Intern Med. 2019;171:153-63. doi: 10.7326/M18-3640.

Two-thirds of patients hospitalized with pneumonia received an excess duration of antibiotics, according to a recent study of more than 6,000 patients.

Longer antibiotic courses did not increase the survival rate or prevent any subsequent health care utilization, authors said; instead, they increased the risk of patient-reported adverse events.

The findings bolster a growing body of evidence showing that short-course therapy for pneumonia is safe and that longer durations are not only unnecessary, but “potentially harmful,” said Valerie M. Vaughn, MD, assistant professor of medicine at the University of Michigan, Ann Arbor, and coinvestigators.

“Reducing excess treatment durations should be a top priority for antibiotic stewardship nationally,” the investigators wrote in their report, which appears in the Annals of Internal Medicine.

The primary analysis of their retrospective cohort study included 6,481 individuals with pneumonia treated at 43 hospitals participating in a statewide quality initiative designed to improve care for hospitalized medical patients at risk of adverse events. About half of the patients were women, and the median age was 70 years. Nearly 60% had severe pneumonia.

The primary outcome of the study was the rate of excess antibiotic therapy duration beyond the shortest expected treatment duration consistent with guidelines. Patients with community-acquired pneumonia (CAP), representing about three-quarters of the study cohort, were expected to have a treatment duration of at least 5 days, while patients with health care–acquired pneumonia (HCAP) were expected to have at least 7 days of treatment.

Overall, 4,391 patients (67.8%) had antibiotic courses longer than the shortest effective duration, with a median duration of 8 days, and a median excess duration of 2 days, the researchers noted.

The great majority of excess days (93.2%) were due to antibiotic prescribed at discharge, according to Dr. Vaughn and colleagues.

Excess treatment duration was not linked to any improvement in 30-day mortality, readmission rates, or subsequent emergency department visits, they found.

In a telephone call at 30 days, 38% of patients treated to excess said they had gone to the doctor for an antibiotic-associated adverse event, compared with 31% who received appropriate-length courses (P = .003).

Odds of a patient-reported adverse event were increased by 5% for every excess treatment day, the investigators wrote.

Taken together, these findings have implications for patient care, research efforts, and future guidelines, according to Dr. Vaughn and coinvestigators.

“The next iteration of CAP and HCAP guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration,” they said in a discussion of their study results.

Dr. Vaughn reported no disclosures related to the study. Coauthors reported grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, personal fees from Wiley Publishing, and royalties from Wolters Kluwer Publishing and Oxford University Press, among other disclosures.

SOURCE: Vaughn VM et al. Ann Intern Med. 2019;171:153-63. doi: 10.7326/M18-3640.

Each July, the largest gathering of pediatric hospitalists occurs, and 2019 is no different! This year, hospitalists who care for children will gather at Pediatric Hospital Medicine (PHM) in Seattle from July 25 to 28, with the goal of enhancing participants’ knowledge and competence in the areas of innovation, clinical medicine, education, health services, practice management, quality improvement, and research.

But what makes this year particularly special is the launch of the subspecialty exam for certification in pediatric hospital medicine coming later this fall, solidifying its growth and importance within hospital medicine and the entire health care landscape. The American Board of Pediatrics (ABP) has approved PHM as the newest board subspecialty with a 2-year fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME). This conference will be a great opportunity to join with others to review competencies for board review, as well as to network with those who are also navigating the road ahead.

During 2019, the Pediatric Hospitalist Special Interest Group (SIG) of SHM has been working tirelessly on several initiatives, including a revision of the Pediatric Hospital Medicine Core Competencies as well as additional work to develop Choosing Wisely 2.0 recommendations. These will help us ensure we are developing the best curricula for the next generation of pediatric hospitalists, while cutting back on unnecessary tests and procedures for those practicing today. Each of these initiatives, as well as the July conference, highlights the opportunities that we have within SHM to work with other like-minded providers who care for children. While we partner with all professionals across many organizations, like the American Academy of Pediatrics and the Academic Pediatric Association to name a few, I wanted to share my reflections on SHM and my appreciation for the “big tent” philosophy that has served us so well thus far.

Having an opportunity to sit on the board of SHM has allowed me a chance to really appreciate the efforts that this organization invests in all who care for patients in the hospital; we have an active group of advanced-practice providers, practice administrators, residents, students, academic hospitalists, and the list goes on and on. We collaborate with a number of spectacular societies dedicated to medical specialties, and we are always open to new ways of improving the methods of delivering care to patients, in hospitals, post-acute care facilities, homes – you name it! As health care delivery models continue to evolve, I believe we are well positioned to be leaders in the delivery of acute care medicine in the hospital and beyond.

I have also learned of happenings at the grassroots level by attending SHM chapter meetings across the United States. For example, the Hampton Roads Chapter led a great Point-of-Care Ultrasound (POCUS) workshop, and influenced by that, I shared an idea at home in Nashville – borrowing my son as a model to demonstrate ultrasound techniques that hospitalists can use to assist in clinical care. I hope you, as pediatric hospitalists, will see if you have a local chapter and attend a meeting; whether you are a member of SHM or not, you can mingle with those who provide acute care treatments to all your communities and share best practices. If you don’t see an SHM chapter close by, let’s get one going! SHM is here to help launch a chapter that can help bring your community together and provide education and networking closer to home.

If you can’t attend PHM in Seattle this year, I hope you will make every effort to be at PHM 2020, where our own SIG leader, Dr. Jeffrey Grill from Louisville, Ky., will be chairing the next rendition of this amazing conference. The SHM Meetings team led by Michelle Kann will be working tirelessly to make it a great event with continued growth in content and attendance.

Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

Each July, the largest gathering of pediatric hospitalists occurs, and 2019 is no different! This year, hospitalists who care for children will gather at Pediatric Hospital Medicine (PHM) in Seattle from July 25 to 28, with the goal of enhancing participants’ knowledge and competence in the areas of innovation, clinical medicine, education, health services, practice management, quality improvement, and research.

But what makes this year particularly special is the launch of the subspecialty exam for certification in pediatric hospital medicine coming later this fall, solidifying its growth and importance within hospital medicine and the entire health care landscape. The American Board of Pediatrics (ABP) has approved PHM as the newest board subspecialty with a 2-year fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME). This conference will be a great opportunity to join with others to review competencies for board review, as well as to network with those who are also navigating the road ahead.

During 2019, the Pediatric Hospitalist Special Interest Group (SIG) of SHM has been working tirelessly on several initiatives, including a revision of the Pediatric Hospital Medicine Core Competencies as well as additional work to develop Choosing Wisely 2.0 recommendations. These will help us ensure we are developing the best curricula for the next generation of pediatric hospitalists, while cutting back on unnecessary tests and procedures for those practicing today. Each of these initiatives, as well as the July conference, highlights the opportunities that we have within SHM to work with other like-minded providers who care for children. While we partner with all professionals across many organizations, like the American Academy of Pediatrics and the Academic Pediatric Association to name a few, I wanted to share my reflections on SHM and my appreciation for the “big tent” philosophy that has served us so well thus far.

Having an opportunity to sit on the board of SHM has allowed me a chance to really appreciate the efforts that this organization invests in all who care for patients in the hospital; we have an active group of advanced-practice providers, practice administrators, residents, students, academic hospitalists, and the list goes on and on. We collaborate with a number of spectacular societies dedicated to medical specialties, and we are always open to new ways of improving the methods of delivering care to patients, in hospitals, post-acute care facilities, homes – you name it! As health care delivery models continue to evolve, I believe we are well positioned to be leaders in the delivery of acute care medicine in the hospital and beyond.

I have also learned of happenings at the grassroots level by attending SHM chapter meetings across the United States. For example, the Hampton Roads Chapter led a great Point-of-Care Ultrasound (POCUS) workshop, and influenced by that, I shared an idea at home in Nashville – borrowing my son as a model to demonstrate ultrasound techniques that hospitalists can use to assist in clinical care. I hope you, as pediatric hospitalists, will see if you have a local chapter and attend a meeting; whether you are a member of SHM or not, you can mingle with those who provide acute care treatments to all your communities and share best practices. If you don’t see an SHM chapter close by, let’s get one going! SHM is here to help launch a chapter that can help bring your community together and provide education and networking closer to home.

If you can’t attend PHM in Seattle this year, I hope you will make every effort to be at PHM 2020, where our own SIG leader, Dr. Jeffrey Grill from Louisville, Ky., will be chairing the next rendition of this amazing conference. The SHM Meetings team led by Michelle Kann will be working tirelessly to make it a great event with continued growth in content and attendance.

Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

Each July, the largest gathering of pediatric hospitalists occurs, and 2019 is no different! This year, hospitalists who care for children will gather at Pediatric Hospital Medicine (PHM) in Seattle from July 25 to 28, with the goal of enhancing participants’ knowledge and competence in the areas of innovation, clinical medicine, education, health services, practice management, quality improvement, and research.

But what makes this year particularly special is the launch of the subspecialty exam for certification in pediatric hospital medicine coming later this fall, solidifying its growth and importance within hospital medicine and the entire health care landscape. The American Board of Pediatrics (ABP) has approved PHM as the newest board subspecialty with a 2-year fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME). This conference will be a great opportunity to join with others to review competencies for board review, as well as to network with those who are also navigating the road ahead.

During 2019, the Pediatric Hospitalist Special Interest Group (SIG) of SHM has been working tirelessly on several initiatives, including a revision of the Pediatric Hospital Medicine Core Competencies as well as additional work to develop Choosing Wisely 2.0 recommendations. These will help us ensure we are developing the best curricula for the next generation of pediatric hospitalists, while cutting back on unnecessary tests and procedures for those practicing today. Each of these initiatives, as well as the July conference, highlights the opportunities that we have within SHM to work with other like-minded providers who care for children. While we partner with all professionals across many organizations, like the American Academy of Pediatrics and the Academic Pediatric Association to name a few, I wanted to share my reflections on SHM and my appreciation for the “big tent” philosophy that has served us so well thus far.

Having an opportunity to sit on the board of SHM has allowed me a chance to really appreciate the efforts that this organization invests in all who care for patients in the hospital; we have an active group of advanced-practice providers, practice administrators, residents, students, academic hospitalists, and the list goes on and on. We collaborate with a number of spectacular societies dedicated to medical specialties, and we are always open to new ways of improving the methods of delivering care to patients, in hospitals, post-acute care facilities, homes – you name it! As health care delivery models continue to evolve, I believe we are well positioned to be leaders in the delivery of acute care medicine in the hospital and beyond.

I have also learned of happenings at the grassroots level by attending SHM chapter meetings across the United States. For example, the Hampton Roads Chapter led a great Point-of-Care Ultrasound (POCUS) workshop, and influenced by that, I shared an idea at home in Nashville – borrowing my son as a model to demonstrate ultrasound techniques that hospitalists can use to assist in clinical care. I hope you, as pediatric hospitalists, will see if you have a local chapter and attend a meeting; whether you are a member of SHM or not, you can mingle with those who provide acute care treatments to all your communities and share best practices. If you don’t see an SHM chapter close by, let’s get one going! SHM is here to help launch a chapter that can help bring your community together and provide education and networking closer to home.

If you can’t attend PHM in Seattle this year, I hope you will make every effort to be at PHM 2020, where our own SIG leader, Dr. Jeffrey Grill from Louisville, Ky., will be chairing the next rendition of this amazing conference. The SHM Meetings team led by Michelle Kann will be working tirelessly to make it a great event with continued growth in content and attendance.

Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

Clinical question: What is the late recurrence rate for patients with uncomplicated appendicitis treated with antibiotics only?

Background: Short-term results support antibiotic treatment as alternative to surgery for uncomplicated appendicitis. Long-term outcomes have not been assessed.

Study design: Observational follow-up.

Setting: Six hospitals in Finland.

Synopsis: The APPAC trial looked at 530 patients, aged 18-60 years, with CT confirmed acute uncomplicated appendicitis, who were randomized to receive either appendectomy or antibiotics. In this follow-up report, outcomes were assessed by telephone interviews conducted 3-5 years after the initial interventions. Overall, 100 of 256 (39.1%) of the antibiotic group ultimately underwent appendectomy within 5 years. Of those, 70/100 (70%) had their recurrence within 1 year of their initial presentation.

Bottom line: Patients with uncomplicated appendicitis treated with antibiotics have a 39% cumulative 5-year recurrence rate, with most recurrences occurring within the first year.

Citation: Salminem P et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-65.

Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Clinical question: What is the late recurrence rate for patients with uncomplicated appendicitis treated with antibiotics only?

Background: Short-term results support antibiotic treatment as alternative to surgery for uncomplicated appendicitis. Long-term outcomes have not been assessed.

Study design: Observational follow-up.

Setting: Six hospitals in Finland.

Synopsis: The APPAC trial looked at 530 patients, aged 18-60 years, with CT confirmed acute uncomplicated appendicitis, who were randomized to receive either appendectomy or antibiotics. In this follow-up report, outcomes were assessed by telephone interviews conducted 3-5 years after the initial interventions. Overall, 100 of 256 (39.1%) of the antibiotic group ultimately underwent appendectomy within 5 years. Of those, 70/100 (70%) had their recurrence within 1 year of their initial presentation.

Bottom line: Patients with uncomplicated appendicitis treated with antibiotics have a 39% cumulative 5-year recurrence rate, with most recurrences occurring within the first year.

Citation: Salminem P et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-65.

Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Clinical question: What is the late recurrence rate for patients with uncomplicated appendicitis treated with antibiotics only?

Background: Short-term results support antibiotic treatment as alternative to surgery for uncomplicated appendicitis. Long-term outcomes have not been assessed.

Study design: Observational follow-up.

Setting: Six hospitals in Finland.

Synopsis: The APPAC trial looked at 530 patients, aged 18-60 years, with CT confirmed acute uncomplicated appendicitis, who were randomized to receive either appendectomy or antibiotics. In this follow-up report, outcomes were assessed by telephone interviews conducted 3-5 years after the initial interventions. Overall, 100 of 256 (39.1%) of the antibiotic group ultimately underwent appendectomy within 5 years. Of those, 70/100 (70%) had their recurrence within 1 year of their initial presentation.

Bottom line: Patients with uncomplicated appendicitis treated with antibiotics have a 39% cumulative 5-year recurrence rate, with most recurrences occurring within the first year.

Citation: Salminem P et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-65.

Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Clinical question: Can differences in hospital readmission rates be explained by patient characteristics not accounted for by Medicare?

Background: In its Pay for Performance program, Medicare ties payments to readmission rates but adjusts these rates only for limited patient characteristics. Hospitals serving higher-risk patients have received greater penalties. These programs may have the unintended consequence of penalizing hospitals that provide care to higher-risk patients.

Study design: Observational study.

Setting: Medicare admissions claims from 2013 through 2014 in 2,215 hospitals.

Synopsis: Using Medicare claims for admission and linked U.S. census data, the study assessed several clinical and social characteristics not currently used for risk adjustment. A sample of 1,169,014 index admissions among 1,003,664 unique beneficiaries was analyzed. The study compared rates with and without these additional adjustments.

Additional adjustments reduced overall variation in hospital readmission by 9.6%, changed rates upward or downward by 0.4%-0.7% for the 10% of hospitals most affected by the readjustments, and they would be expected to reduce penalties by 52%, 46%, and 41% for hospitals with the largest 1%, 5%, and 10% of penalty reductions, respectively.

Bottom line: Hospitals serving higher-risk patients may be penalized because of the patients they serve rather that the quality of care they provide.

Citation: Roberts ET et al. Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: Implications for Pay for Performance. JAMA Intern Med. 2018;178(11)1498-1507.

Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Clinical question: Can differences in hospital readmission rates be explained by patient characteristics not accounted for by Medicare?

Background: In its Pay for Performance program, Medicare ties payments to readmission rates but adjusts these rates only for limited patient characteristics. Hospitals serving higher-risk patients have received greater penalties. These programs may have the unintended consequence of penalizing hospitals that provide care to higher-risk patients.

Study design: Observational study.

Setting: Medicare admissions claims from 2013 through 2014 in 2,215 hospitals.

Synopsis: Using Medicare claims for admission and linked U.S. census data, the study assessed several clinical and social characteristics not currently used for risk adjustment. A sample of 1,169,014 index admissions among 1,003,664 unique beneficiaries was analyzed. The study compared rates with and without these additional adjustments.

Additional adjustments reduced overall variation in hospital readmission by 9.6%, changed rates upward or downward by 0.4%-0.7% for the 10% of hospitals most affected by the readjustments, and they would be expected to reduce penalties by 52%, 46%, and 41% for hospitals with the largest 1%, 5%, and 10% of penalty reductions, respectively.

Bottom line: Hospitals serving higher-risk patients may be penalized because of the patients they serve rather that the quality of care they provide.

Citation: Roberts ET et al. Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: Implications for Pay for Performance. JAMA Intern Med. 2018;178(11)1498-1507.

Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Clinical question: Can differences in hospital readmission rates be explained by patient characteristics not accounted for by Medicare?

Background: In its Pay for Performance program, Medicare ties payments to readmission rates but adjusts these rates only for limited patient characteristics. Hospitals serving higher-risk patients have received greater penalties. These programs may have the unintended consequence of penalizing hospitals that provide care to higher-risk patients.

Study design: Observational study.

Setting: Medicare admissions claims from 2013 through 2014 in 2,215 hospitals.

Synopsis: Using Medicare claims for admission and linked U.S. census data, the study assessed several clinical and social characteristics not currently used for risk adjustment. A sample of 1,169,014 index admissions among 1,003,664 unique beneficiaries was analyzed. The study compared rates with and without these additional adjustments.

Additional adjustments reduced overall variation in hospital readmission by 9.6%, changed rates upward or downward by 0.4%-0.7% for the 10% of hospitals most affected by the readjustments, and they would be expected to reduce penalties by 52%, 46%, and 41% for hospitals with the largest 1%, 5%, and 10% of penalty reductions, respectively.

Bottom line: Hospitals serving higher-risk patients may be penalized because of the patients they serve rather that the quality of care they provide.

Citation: Roberts ET et al. Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: Implications for Pay for Performance. JAMA Intern Med. 2018;178(11)1498-1507.

Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?

Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week^®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.

In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.

Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.

In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.

And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.

Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.

What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.

For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.

She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.

Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).

These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”

Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.

Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.

Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.

Dr. Burke reported no relevant conflicts of interest.

[email protected]

SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?

Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week^®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.

In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.

Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.

In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.

And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.

Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.

What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.

For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.

She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.

Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).

These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”

Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.

Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.

Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.

Dr. Burke reported no relevant conflicts of interest.

[email protected]

SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?

Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week^®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.

In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.

Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.

In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.

And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.

Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.

What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.

For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.

She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.

Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).

These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”

Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.

Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.

Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.

Dr. Burke reported no relevant conflicts of interest.

[email protected]

Let’s begin with a brief case. A 25-year-old patient with a history of injection heroin use is in your care. He is admitted for treatment of endocarditis and will remain in the hospital for intravenous antibiotics for several weeks. Over the first few days of hospitalization, he frequently asks for pain medicine, stating that he is in severe pain, withdrawal, and having opioid cravings. On day 3, he leaves the hospital against medical advice. After 2 weeks, he presents to the ED in septic shock and spends several weeks in the ICU. Or, alternatively, he is found down in the community and pronounced dead from a heroin overdose.

These cases occur all too often, and hospitalists across the nation are actively building knowledge and programs to improve care for patients with opioid use disorder (OUD). It is evident that opioid misuse is the public health crisis of our time. In 2017, over 70,000 patients died from an overdose, and over 2 million patients in the United States have a diagnosis of OUD.^1,2 Many of these patients interact with the hospital at some point during the course of their illness for management of overdose, withdrawal, and other complications of OUD, including endocarditis, osteomyelitis, and skin and soft tissue infections. Moreover, just 20% of the 580,000 patients hospitalized with OUD in 2015 presented as a direct sequelae of the disease.³ Patients with OUD are often admitted for unrelated reasons, but their addiction goes unaddressed.

Opioid use disorder, like many of the other conditions we see, is a chronic relapsing remitting medical disease and a risk factor for premature mortality. When a patient with diabetes is admitted with cellulitis, we might check an A_1C, provide diabetic counseling, and offer evidence-based diabetes treatment, including medications like insulin. We rarely build similar systems of care within the walls of our hospitals to treat OUD like we do for diabetes or other commonly encountered diseases like heart failure and chronic obstructive pulmonary disease.

We should be intentional about separating prevention from treatment. Significant work has gone into reducing the availability of prescription opioids and increasing utilization of prescription drug monitoring programs. As a result, the average morphine milligram equivalent per opioid prescription has decreased since 2010.⁴ An unintended consequence of restricting legal opioids is potentially pushing patients with opioid addiction towards heroin and fentanyl. Limiting opioid prescriptions alone will only decrease opioid overdose mortality by 5% through 2025.⁵ Thus, treatment of OUD is critical and something that hospitalists should be trained and engaged in.

Food and Drug Administration–approved OUD treatment includes buprenorphine, methadone, and extended-release naltrexone. Buprenorphine is a partial opioid agonist that treats withdrawal and cravings. Buprenorphine started in the hospital reduces mortality, increases time spent in outpatient treatment after discharge, and reduces opioid-related 30-day readmissions by over 50%.^6-8 The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.⁹ While physicians require an 8-hour “x-waiver” training (physician assistants and nurse practitioners require a 24-hour training) to prescribe buprenorphine for the outpatient treatment of OUD, such certification is not required to order the medication as part of an acute hospitalization.

Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD. Patients are away from triggering environments and surrounded by supportive staff. Unfortunately, up to 30% of these patients leave the hospital against medical advice because of inadequately treated withdrawal, unaddressed cravings, and fear of mistreatment.¹⁰ Buprenorphine therapy may help tackle the physiological piece of hospital-based treatment, but we also must work on shifting the culture of our institutions. Importantly, OUD is a medical diagnosis. These patients must receive the same dignity, autonomy, and meaningful care afforded to patients with other medical diagnoses. Patients with OUD are not “addicts,” “abusers,” or “frequent fliers.”

Hospitalists have a clear and compelling role in treating OUD. The National Academy of Medicine recently held a workshop where they compared similarities of the HIV crisis with today’s opioid epidemic. The Academy advocated for the development of hospital-based protocols that empower physicians, physician assistants, and nurse practitioners to integrate the treatment of OUD into their practice.¹¹ Some in our field may feel that treating underlying addiction is a role for behavioral health practitioners. This is akin to having said that HIV specialists should be the only providers to treat patients with HIV during its peak. There are simply not enough psychiatrists or addiction medicine specialists to treat all of the patients who need us during this time of national urgency.

Mr. Bottner is a hospitalist at Dell Seton Medical Center, Austin, Texas, and clinical assistant professor at the University of Texas at Austin.

References

1. Katz J. You draw it: Just how bad is the drug overdose epidemic? New York Times. https://www.nytimes.com/interactive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it.html. Published Oct 26, 2017.

2. National Institute on Drug Abuse. Ohio – Opioid summaries by state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ohio_2018.pdf.

3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39. doi: 10.1016/j.jsat.2018.06.008.

4. Guy GP. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4.

5. Chen Q et al. Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.7621.

6. Liebschutz J et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76.

7. Moreno JL et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019. doi: 10.1097/ADM.0000000000000499.

8. Larochelle MR et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi: 10.7326/M17-3107.

9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp.org/afp/2017/0301/od1.html. Accessed May 12, 2019.

10. Ti L et al. Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. Am J Public Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a.

11. Springer SAM et al. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: A call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-6. doi: 10.7326/M18-1203.

Let’s begin with a brief case. A 25-year-old patient with a history of injection heroin use is in your care. He is admitted for treatment of endocarditis and will remain in the hospital for intravenous antibiotics for several weeks. Over the first few days of hospitalization, he frequently asks for pain medicine, stating that he is in severe pain, withdrawal, and having opioid cravings. On day 3, he leaves the hospital against medical advice. After 2 weeks, he presents to the ED in septic shock and spends several weeks in the ICU. Or, alternatively, he is found down in the community and pronounced dead from a heroin overdose.

These cases occur all too often, and hospitalists across the nation are actively building knowledge and programs to improve care for patients with opioid use disorder (OUD). It is evident that opioid misuse is the public health crisis of our time. In 2017, over 70,000 patients died from an overdose, and over 2 million patients in the United States have a diagnosis of OUD.^1,2 Many of these patients interact with the hospital at some point during the course of their illness for management of overdose, withdrawal, and other complications of OUD, including endocarditis, osteomyelitis, and skin and soft tissue infections. Moreover, just 20% of the 580,000 patients hospitalized with OUD in 2015 presented as a direct sequelae of the disease.³ Patients with OUD are often admitted for unrelated reasons, but their addiction goes unaddressed.

Opioid use disorder, like many of the other conditions we see, is a chronic relapsing remitting medical disease and a risk factor for premature mortality. When a patient with diabetes is admitted with cellulitis, we might check an A_1C, provide diabetic counseling, and offer evidence-based diabetes treatment, including medications like insulin. We rarely build similar systems of care within the walls of our hospitals to treat OUD like we do for diabetes or other commonly encountered diseases like heart failure and chronic obstructive pulmonary disease.

We should be intentional about separating prevention from treatment. Significant work has gone into reducing the availability of prescription opioids and increasing utilization of prescription drug monitoring programs. As a result, the average morphine milligram equivalent per opioid prescription has decreased since 2010.⁴ An unintended consequence of restricting legal opioids is potentially pushing patients with opioid addiction towards heroin and fentanyl. Limiting opioid prescriptions alone will only decrease opioid overdose mortality by 5% through 2025.⁵ Thus, treatment of OUD is critical and something that hospitalists should be trained and engaged in.

Food and Drug Administration–approved OUD treatment includes buprenorphine, methadone, and extended-release naltrexone. Buprenorphine is a partial opioid agonist that treats withdrawal and cravings. Buprenorphine started in the hospital reduces mortality, increases time spent in outpatient treatment after discharge, and reduces opioid-related 30-day readmissions by over 50%.^6-8 The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.⁹ While physicians require an 8-hour “x-waiver” training (physician assistants and nurse practitioners require a 24-hour training) to prescribe buprenorphine for the outpatient treatment of OUD, such certification is not required to order the medication as part of an acute hospitalization.

Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD. Patients are away from triggering environments and surrounded by supportive staff. Unfortunately, up to 30% of these patients leave the hospital against medical advice because of inadequately treated withdrawal, unaddressed cravings, and fear of mistreatment.¹⁰ Buprenorphine therapy may help tackle the physiological piece of hospital-based treatment, but we also must work on shifting the culture of our institutions. Importantly, OUD is a medical diagnosis. These patients must receive the same dignity, autonomy, and meaningful care afforded to patients with other medical diagnoses. Patients with OUD are not “addicts,” “abusers,” or “frequent fliers.”

Hospitalists have a clear and compelling role in treating OUD. The National Academy of Medicine recently held a workshop where they compared similarities of the HIV crisis with today’s opioid epidemic. The Academy advocated for the development of hospital-based protocols that empower physicians, physician assistants, and nurse practitioners to integrate the treatment of OUD into their practice.¹¹ Some in our field may feel that treating underlying addiction is a role for behavioral health practitioners. This is akin to having said that HIV specialists should be the only providers to treat patients with HIV during its peak. There are simply not enough psychiatrists or addiction medicine specialists to treat all of the patients who need us during this time of national urgency.

Mr. Bottner is a hospitalist at Dell Seton Medical Center, Austin, Texas, and clinical assistant professor at the University of Texas at Austin.

References

1. Katz J. You draw it: Just how bad is the drug overdose epidemic? New York Times. https://www.nytimes.com/interactive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it.html. Published Oct 26, 2017.

2. National Institute on Drug Abuse. Ohio – Opioid summaries by state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ohio_2018.pdf.

3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39. doi: 10.1016/j.jsat.2018.06.008.

4. Guy GP. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4.

5. Chen Q et al. Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.7621.

6. Liebschutz J et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76.

7. Moreno JL et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019. doi: 10.1097/ADM.0000000000000499.

8. Larochelle MR et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi: 10.7326/M17-3107.

9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp.org/afp/2017/0301/od1.html. Accessed May 12, 2019.

10. Ti L et al. Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. Am J Public Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a.

11. Springer SAM et al. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: A call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-6. doi: 10.7326/M18-1203.

Let’s begin with a brief case. A 25-year-old patient with a history of injection heroin use is in your care. He is admitted for treatment of endocarditis and will remain in the hospital for intravenous antibiotics for several weeks. Over the first few days of hospitalization, he frequently asks for pain medicine, stating that he is in severe pain, withdrawal, and having opioid cravings. On day 3, he leaves the hospital against medical advice. After 2 weeks, he presents to the ED in septic shock and spends several weeks in the ICU. Or, alternatively, he is found down in the community and pronounced dead from a heroin overdose.

These cases occur all too often, and hospitalists across the nation are actively building knowledge and programs to improve care for patients with opioid use disorder (OUD). It is evident that opioid misuse is the public health crisis of our time. In 2017, over 70,000 patients died from an overdose, and over 2 million patients in the United States have a diagnosis of OUD.^1,2 Many of these patients interact with the hospital at some point during the course of their illness for management of overdose, withdrawal, and other complications of OUD, including endocarditis, osteomyelitis, and skin and soft tissue infections. Moreover, just 20% of the 580,000 patients hospitalized with OUD in 2015 presented as a direct sequelae of the disease.³ Patients with OUD are often admitted for unrelated reasons, but their addiction goes unaddressed.

Opioid use disorder, like many of the other conditions we see, is a chronic relapsing remitting medical disease and a risk factor for premature mortality. When a patient with diabetes is admitted with cellulitis, we might check an A_1C, provide diabetic counseling, and offer evidence-based diabetes treatment, including medications like insulin. We rarely build similar systems of care within the walls of our hospitals to treat OUD like we do for diabetes or other commonly encountered diseases like heart failure and chronic obstructive pulmonary disease.

We should be intentional about separating prevention from treatment. Significant work has gone into reducing the availability of prescription opioids and increasing utilization of prescription drug monitoring programs. As a result, the average morphine milligram equivalent per opioid prescription has decreased since 2010.⁴ An unintended consequence of restricting legal opioids is potentially pushing patients with opioid addiction towards heroin and fentanyl. Limiting opioid prescriptions alone will only decrease opioid overdose mortality by 5% through 2025.⁵ Thus, treatment of OUD is critical and something that hospitalists should be trained and engaged in.

Food and Drug Administration–approved OUD treatment includes buprenorphine, methadone, and extended-release naltrexone. Buprenorphine is a partial opioid agonist that treats withdrawal and cravings. Buprenorphine started in the hospital reduces mortality, increases time spent in outpatient treatment after discharge, and reduces opioid-related 30-day readmissions by over 50%.^6-8 The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.⁹ While physicians require an 8-hour “x-waiver” training (physician assistants and nurse practitioners require a 24-hour training) to prescribe buprenorphine for the outpatient treatment of OUD, such certification is not required to order the medication as part of an acute hospitalization.

Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD. Patients are away from triggering environments and surrounded by supportive staff. Unfortunately, up to 30% of these patients leave the hospital against medical advice because of inadequately treated withdrawal, unaddressed cravings, and fear of mistreatment.¹⁰ Buprenorphine therapy may help tackle the physiological piece of hospital-based treatment, but we also must work on shifting the culture of our institutions. Importantly, OUD is a medical diagnosis. These patients must receive the same dignity, autonomy, and meaningful care afforded to patients with other medical diagnoses. Patients with OUD are not “addicts,” “abusers,” or “frequent fliers.”

Hospitalists have a clear and compelling role in treating OUD. The National Academy of Medicine recently held a workshop where they compared similarities of the HIV crisis with today’s opioid epidemic. The Academy advocated for the development of hospital-based protocols that empower physicians, physician assistants, and nurse practitioners to integrate the treatment of OUD into their practice.¹¹ Some in our field may feel that treating underlying addiction is a role for behavioral health practitioners. This is akin to having said that HIV specialists should be the only providers to treat patients with HIV during its peak. There are simply not enough psychiatrists or addiction medicine specialists to treat all of the patients who need us during this time of national urgency.

Mr. Bottner is a hospitalist at Dell Seton Medical Center, Austin, Texas, and clinical assistant professor at the University of Texas at Austin.

References

1. Katz J. You draw it: Just how bad is the drug overdose epidemic? New York Times. https://www.nytimes.com/interactive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it.html. Published Oct 26, 2017.

2. National Institute on Drug Abuse. Ohio – Opioid summaries by state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ohio_2018.pdf.

3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39. doi: 10.1016/j.jsat.2018.06.008.

4. Guy GP. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4.

5. Chen Q et al. Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.7621.

6. Liebschutz J et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76.

7. Moreno JL et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019. doi: 10.1097/ADM.0000000000000499.

8. Larochelle MR et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi: 10.7326/M17-3107.

9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp.org/afp/2017/0301/od1.html. Accessed May 12, 2019.

10. Ti L et al. Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. Am J Public Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a.

11. Springer SAM et al. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: A call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-6. doi: 10.7326/M18-1203.

Background: SDDs are as safe as non-SDDs (NSDDs) in patients after elective PCI, yet there has been only a modest increase in SDD.

Limitations include that 2015 data may not reflect current practices. ICD 9 codes used for obtaining complications data can be misclassified. Cost savings are variable. Patients with periprocedural complications were not candidates for SDD but were included in the data. The study does not account for variation in technique, PCI characteristics, or SDD criteria of hospitals.

Bottom line: Prevalence of SDDs for elective PCI patients varies by institution and is an underutilized opportunity to significantly reduce hospital costs and increase patient satisfaction while maintaining the safety of patients.

Citation: Amin AP et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. Published online 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029.

Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Background: SDDs are as safe as non-SDDs (NSDDs) in patients after elective PCI, yet there has been only a modest increase in SDD.

Limitations include that 2015 data may not reflect current practices. ICD 9 codes used for obtaining complications data can be misclassified. Cost savings are variable. Patients with periprocedural complications were not candidates for SDD but were included in the data. The study does not account for variation in technique, PCI characteristics, or SDD criteria of hospitals.

Bottom line: Prevalence of SDDs for elective PCI patients varies by institution and is an underutilized opportunity to significantly reduce hospital costs and increase patient satisfaction while maintaining the safety of patients.

Citation: Amin AP et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. Published online 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029.

Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Background: SDDs are as safe as non-SDDs (NSDDs) in patients after elective PCI, yet there has been only a modest increase in SDD.

Limitations include that 2015 data may not reflect current practices. ICD 9 codes used for obtaining complications data can be misclassified. Cost savings are variable. Patients with periprocedural complications were not candidates for SDD but were included in the data. The study does not account for variation in technique, PCI characteristics, or SDD criteria of hospitals.

Bottom line: Prevalence of SDDs for elective PCI patients varies by institution and is an underutilized opportunity to significantly reduce hospital costs and increase patient satisfaction while maintaining the safety of patients.

Citation: Amin AP et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. Published online 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029.

Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Background: In patients with primary degenerative MR, MVR is curative, with the transcatheter approach being safer than surgical repair. However, it is unknown whether patients with secondary MR from left ventricular dilatation would confer the same benefit of MVR.

Limitations include that investigators were not blinded because the device was visible on imaging. Longer follow-up in the device group may have contributed to the observed decreased mortality. It is unknown whether less-symptomatic patients would attain the same benefit.

Bottom line: In patients with symptomatic, moderate to severe, and severe secondary MR, MVR lowers rates of hospitalization, decreases mortality, and improves quality of life.

Citation: Stone GW et al. Trans­catheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23. doi: 10.1056/NEJMoa1806640.
 

Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Background: In patients with primary degenerative MR, MVR is curative, with the transcatheter approach being safer than surgical repair. However, it is unknown whether patients with secondary MR from left ventricular dilatation would confer the same benefit of MVR.

Limitations include that investigators were not blinded because the device was visible on imaging. Longer follow-up in the device group may have contributed to the observed decreased mortality. It is unknown whether less-symptomatic patients would attain the same benefit.

Bottom line: In patients with symptomatic, moderate to severe, and severe secondary MR, MVR lowers rates of hospitalization, decreases mortality, and improves quality of life.

Citation: Stone GW et al. Trans­catheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23. doi: 10.1056/NEJMoa1806640.
 

Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

Background: In patients with primary degenerative MR, MVR is curative, with the transcatheter approach being safer than surgical repair. However, it is unknown whether patients with secondary MR from left ventricular dilatation would confer the same benefit of MVR.

Limitations include that investigators were not blinded because the device was visible on imaging. Longer follow-up in the device group may have contributed to the observed decreased mortality. It is unknown whether less-symptomatic patients would attain the same benefit.

Bottom line: In patients with symptomatic, moderate to severe, and severe secondary MR, MVR lowers rates of hospitalization, decreases mortality, and improves quality of life.

Citation: Stone GW et al. Trans­catheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23. doi: 10.1056/NEJMoa1806640.
 

Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.