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Residents curb IV antibiotic overuse in children
ATLANTA – It took less than a year to curb overuse of intravenous antibiotics at the Cincinnati Children’s Hospital, according to a report given at the Pediatric Hospital Medicine meeting.
Overuse of IV antibiotics – continuing IV formulations when oral formulations would work just as well – is a widespread concern in hospital medicine. Patients can often be switched to an oral antibiotic after an initial IV course. It lowers costs, lessens the risk of antimicrobial resistance, and reduces IV complications, but timely transitions don’t always happen.
They certainly weren’t happening at Cincinnati Children’s. “Despite a strong antimicrobial stewardship program, we identified a problem with overuse of IV antibiotics. The majority of pediatric patients admitted to an in-hospital service were started on IV antibiotics regardless of diagnosis or condition. Conversion to enteral antibiotics was often not considered until the day of discharge, even if patients were taking other enteral medications earlier in the admission,” said project leader Sonya Girdwood, MD, a research fellow at the hospital.
To get a handle on the problem, her team focused on two common IV antibiotics, ampicillin and clindamycin, that have oral equivalents with equal bioavailability: amoxicillin in the case of ampicillin, and oral clindamycin. To further define the project, they zeroed in on two common indications: clindamycin for uncomplicated skin and soft-tissue infections, and ampicillin for community-acquired pneumonia, in children over 2 months old.
The team figured that, if patients were able to take other oral medications, they should also be able to take oral antibiotics, so the goal of the project was to increase the rate of antibiotics given orally in children who were taking other enteral medications.
That percentage was 44% at baseline, and increased to 80% by month 8, saving an estimated $30,000 annually. There was no increase in 30-day readmissions. Length of stay held steady overall at about a day and half, but Dr. Girdwood suspected it might have been reduced for cellulitis.
Improvement efforts focused on residents and started in January 2017. Among the first lessons was that IV ampicillin is about 21 times more expensive than amoxicillin and that IV clindamycin is about twice as expensive as its oral formulation.
Residents were tasked with forming a plan at admission to transition children to oral antibiotics as soon as possible and to discuss those plans with attending physicians in preround huddles. Often, “this led to [transition] orders being placed even before rounds started,” Dr. Girdwood said.
A time was set up during evening huddles – 10 p.m. – for residents working overnight to discuss transition timing with attending. Failures – patients still on IV clindamycin or ampicillin when they were taking oral meds – were identified and shared with resident teams.
The gains have been maintained for almost a year with little backsliding; residents are reminded weekly of transition goals.
Children with skin and soft-tissue infections with bone or eye involvement were excluded from the project, along with pneumonia patients with chest tubes or complex or loculated effusions requiring a surgery consult.
There was no external funding, and the investigators had no disclosures.
ATLANTA – It took less than a year to curb overuse of intravenous antibiotics at the Cincinnati Children’s Hospital, according to a report given at the Pediatric Hospital Medicine meeting.
Overuse of IV antibiotics – continuing IV formulations when oral formulations would work just as well – is a widespread concern in hospital medicine. Patients can often be switched to an oral antibiotic after an initial IV course. It lowers costs, lessens the risk of antimicrobial resistance, and reduces IV complications, but timely transitions don’t always happen.
They certainly weren’t happening at Cincinnati Children’s. “Despite a strong antimicrobial stewardship program, we identified a problem with overuse of IV antibiotics. The majority of pediatric patients admitted to an in-hospital service were started on IV antibiotics regardless of diagnosis or condition. Conversion to enteral antibiotics was often not considered until the day of discharge, even if patients were taking other enteral medications earlier in the admission,” said project leader Sonya Girdwood, MD, a research fellow at the hospital.
To get a handle on the problem, her team focused on two common IV antibiotics, ampicillin and clindamycin, that have oral equivalents with equal bioavailability: amoxicillin in the case of ampicillin, and oral clindamycin. To further define the project, they zeroed in on two common indications: clindamycin for uncomplicated skin and soft-tissue infections, and ampicillin for community-acquired pneumonia, in children over 2 months old.
The team figured that, if patients were able to take other oral medications, they should also be able to take oral antibiotics, so the goal of the project was to increase the rate of antibiotics given orally in children who were taking other enteral medications.
That percentage was 44% at baseline, and increased to 80% by month 8, saving an estimated $30,000 annually. There was no increase in 30-day readmissions. Length of stay held steady overall at about a day and half, but Dr. Girdwood suspected it might have been reduced for cellulitis.
Improvement efforts focused on residents and started in January 2017. Among the first lessons was that IV ampicillin is about 21 times more expensive than amoxicillin and that IV clindamycin is about twice as expensive as its oral formulation.
Residents were tasked with forming a plan at admission to transition children to oral antibiotics as soon as possible and to discuss those plans with attending physicians in preround huddles. Often, “this led to [transition] orders being placed even before rounds started,” Dr. Girdwood said.
A time was set up during evening huddles – 10 p.m. – for residents working overnight to discuss transition timing with attending. Failures – patients still on IV clindamycin or ampicillin when they were taking oral meds – were identified and shared with resident teams.
The gains have been maintained for almost a year with little backsliding; residents are reminded weekly of transition goals.
Children with skin and soft-tissue infections with bone or eye involvement were excluded from the project, along with pneumonia patients with chest tubes or complex or loculated effusions requiring a surgery consult.
There was no external funding, and the investigators had no disclosures.
ATLANTA – It took less than a year to curb overuse of intravenous antibiotics at the Cincinnati Children’s Hospital, according to a report given at the Pediatric Hospital Medicine meeting.
Overuse of IV antibiotics – continuing IV formulations when oral formulations would work just as well – is a widespread concern in hospital medicine. Patients can often be switched to an oral antibiotic after an initial IV course. It lowers costs, lessens the risk of antimicrobial resistance, and reduces IV complications, but timely transitions don’t always happen.
They certainly weren’t happening at Cincinnati Children’s. “Despite a strong antimicrobial stewardship program, we identified a problem with overuse of IV antibiotics. The majority of pediatric patients admitted to an in-hospital service were started on IV antibiotics regardless of diagnosis or condition. Conversion to enteral antibiotics was often not considered until the day of discharge, even if patients were taking other enteral medications earlier in the admission,” said project leader Sonya Girdwood, MD, a research fellow at the hospital.
To get a handle on the problem, her team focused on two common IV antibiotics, ampicillin and clindamycin, that have oral equivalents with equal bioavailability: amoxicillin in the case of ampicillin, and oral clindamycin. To further define the project, they zeroed in on two common indications: clindamycin for uncomplicated skin and soft-tissue infections, and ampicillin for community-acquired pneumonia, in children over 2 months old.
The team figured that, if patients were able to take other oral medications, they should also be able to take oral antibiotics, so the goal of the project was to increase the rate of antibiotics given orally in children who were taking other enteral medications.
That percentage was 44% at baseline, and increased to 80% by month 8, saving an estimated $30,000 annually. There was no increase in 30-day readmissions. Length of stay held steady overall at about a day and half, but Dr. Girdwood suspected it might have been reduced for cellulitis.
Improvement efforts focused on residents and started in January 2017. Among the first lessons was that IV ampicillin is about 21 times more expensive than amoxicillin and that IV clindamycin is about twice as expensive as its oral formulation.
Residents were tasked with forming a plan at admission to transition children to oral antibiotics as soon as possible and to discuss those plans with attending physicians in preround huddles. Often, “this led to [transition] orders being placed even before rounds started,” Dr. Girdwood said.
A time was set up during evening huddles – 10 p.m. – for residents working overnight to discuss transition timing with attending. Failures – patients still on IV clindamycin or ampicillin when they were taking oral meds – were identified and shared with resident teams.
The gains have been maintained for almost a year with little backsliding; residents are reminded weekly of transition goals.
Children with skin and soft-tissue infections with bone or eye involvement were excluded from the project, along with pneumonia patients with chest tubes or complex or loculated effusions requiring a surgery consult.
There was no external funding, and the investigators had no disclosures.
REPORTING FROM PHM 2018
Key clinical point:
Major finding: The percentage of antibiotics given orally to children who were taking other enteral medications rose from 44% to 80% over 8 months, saving an estimated $30,000 annually.
Study details: Quality improvement project
Disclosures: There was no external funding, and the investigators didn’t have any disclosures.
Trump, not health care, likely focus of midterm elections
Provider community must be “creative and participative”
Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.
Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?
Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”
Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.
“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”
What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.
In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.
However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”
MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.
The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.
“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.1
CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.
“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”
However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.
“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.
At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.2 However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.
He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.
As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”
However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.3 It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.
Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.
“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
References
1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.
2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.
3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
Provider community must be “creative and participative”
Provider community must be “creative and participative”
Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.
Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?
Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”
Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.
“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”
What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.
In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.
However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”
MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.
The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.
“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.1
CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.
“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”
However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.
“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.
At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.2 However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.
He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.
As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”
However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.3 It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.
Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.
“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
References
1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.
2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.
3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.
Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?
Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”
Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.
“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”
What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.
In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.
However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”
MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.
The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.
“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.1
CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.
“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”
However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.
“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.
At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.2 However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.
He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.
As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”
However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.3 It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.
Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.
“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
References
1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.
2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.
3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
Most in-hospital pneumonia deaths may not be preventable
Most in-hospital deaths from community-acquired pneumonia are not preventable with current medical therapy, according to an analysis of deaths at five U.S. hospitals with expertise in pneumonia care.
Adults who are hospitalized with community-acquired pneumonia (CAP) are at high risk for short-term mortality but it is unclear whether an improvement in care could lower this risk, noted the study authors led by Grant W. Waterer, MBBS, PhD, of Northwestern University, Chicago.
“Understanding the circumstances in which CAP patients die could facilitate improvements in the management of CAP by enabling future improvement efforts to focus on common preventable causes of death,” they wrote. Their report was published in CHEST®.
They therefore performed a secondary analysis of the Etiology of Pneumonia in the Community (EPIC) study involving adults hospitalized with CAP between January 2010 and June 2012 across five tertiary-care hospitals in the United States.
The clinical characteristics of patients who died in the hospital were compared with those of patients who survived to hospital discharge. Chronic heart failure, chronic obstructive pulmonary disease, coronary artery disease, chronic liver disease, cerebrovascular disease, cancer (excluding skin cancer), and diabetes were considered as severe chronic comorbidities based on their association with increased mortality and ICU admission in CAP severity scores.
Deaths caused by septic shock, respiratory failure, multisystem organ failure, cardiopulmonary arrest prior to stabilization of CAP, and endocarditis, were considered to be directly related to CAP.
Conversely, causes of death indirectly related to CAP included acute cardiovascular disease, stroke, acute renal failure, and secondary infections developed after hospitalization. Deaths caused by cancer, cirrhosis, and chronic neurologic conditions were considered unrelated to CAP.
Medical notes were assessed to determine whether the patient received management consistent with current recommendations; for example, antibiotics consistent with guidelines from the Infectious Diseases Society of America.
End-of-life limitations in care, such as patient/family decision not to proceed with full medical treatment, also were considered by the research team.
Results showed that among the 2,320 patients with radiographically confirmed CAP, 52 died during initial hospitalization, 33 of whom were aged 65 years or older, and 32 of whom had two or more chronic comorbidities.
Most of the in-hospital deaths occurred early in the hospitalization: 35 within the first 10 days of admission, and 5 after 30 days in hospital.
CAP was judged by an expert physician review panel to be the direct cause of death in 27 of the patients, 10 with CAP having an indirect role with major contribution, 9 with CAP having an indirect role with minor contribution, and 6 with CAP having no role in death.
Do-not-resuscitate orders were present at the time of death for 21 of the patients.
Forty-five of the patients were admitted to an ICU, with 37 dying in the ICU. The eight patients who died on the ward after transfer out of the ICU had end-of-life limitations of care in place.
The researchers noted that the number of patients dying in the ICU was greater in the United States, possibly because in Europe fewer patients are admitted to an ICU.
“This discrepancy likely reflects cultural differences between the U.S. and Europe in the role of intensive care for patients with advanced age and/or advanced comorbid conditions,” they noted.
Overall, the physician review panel identified nine patients who had a lapse in quality of in-hospital CAP care, with four of the deaths potentially linked to this lapse in care.
However, two of the patients had end-of-life limitations of care in place, which according to the authors meant that “only two patients undergoing full medical treatment without end-of-life limitations of care had an identified lapse in quality of in-hospital pneumonia care potentially contributing to in-hospital death, including one with a delay in antibiotics for over an hour in the presence of shock and one with initial antibiotics not consistent with IDSA/ATS guidelines.”
The research team concluded that most in-hospital deaths among adult patients admitted with CAP in their study would not have been preventable with higher quality in-hospital pneumonia care.
“Many of the in-hospital deaths among patients admitted with CAP occurred in older patients with severe comorbidities and end-of-life limitations in care,” they noted.
They said the influence of end-of-life limitations on care short of full palliation was an important finding, with all patients who died outside the ICU having end-of-life limitations in care.
“Current diagnostic related group (DRG) and international classification of diseases (ICD) coding systems do not have the necessary nuances to capture these limitations of care, yet they are clearly important factors in determining whether patients experience in-hospital death,” they added.
Dr. Waterer reported no conflicts. Two coauthors reported potential conflicts of interest in relation to consulting fees from several pharmaceutical companies.
SOURCE: Waterer G. et al. CHEST 2018;154(3):628-35. doi: 10.1016/j.chest.2018.05.021.
Most in-hospital deaths from community-acquired pneumonia are not preventable with current medical therapy, according to an analysis of deaths at five U.S. hospitals with expertise in pneumonia care.
Adults who are hospitalized with community-acquired pneumonia (CAP) are at high risk for short-term mortality but it is unclear whether an improvement in care could lower this risk, noted the study authors led by Grant W. Waterer, MBBS, PhD, of Northwestern University, Chicago.
“Understanding the circumstances in which CAP patients die could facilitate improvements in the management of CAP by enabling future improvement efforts to focus on common preventable causes of death,” they wrote. Their report was published in CHEST®.
They therefore performed a secondary analysis of the Etiology of Pneumonia in the Community (EPIC) study involving adults hospitalized with CAP between January 2010 and June 2012 across five tertiary-care hospitals in the United States.
The clinical characteristics of patients who died in the hospital were compared with those of patients who survived to hospital discharge. Chronic heart failure, chronic obstructive pulmonary disease, coronary artery disease, chronic liver disease, cerebrovascular disease, cancer (excluding skin cancer), and diabetes were considered as severe chronic comorbidities based on their association with increased mortality and ICU admission in CAP severity scores.
Deaths caused by septic shock, respiratory failure, multisystem organ failure, cardiopulmonary arrest prior to stabilization of CAP, and endocarditis, were considered to be directly related to CAP.
Conversely, causes of death indirectly related to CAP included acute cardiovascular disease, stroke, acute renal failure, and secondary infections developed after hospitalization. Deaths caused by cancer, cirrhosis, and chronic neurologic conditions were considered unrelated to CAP.
Medical notes were assessed to determine whether the patient received management consistent with current recommendations; for example, antibiotics consistent with guidelines from the Infectious Diseases Society of America.
End-of-life limitations in care, such as patient/family decision not to proceed with full medical treatment, also were considered by the research team.
Results showed that among the 2,320 patients with radiographically confirmed CAP, 52 died during initial hospitalization, 33 of whom were aged 65 years or older, and 32 of whom had two or more chronic comorbidities.
Most of the in-hospital deaths occurred early in the hospitalization: 35 within the first 10 days of admission, and 5 after 30 days in hospital.
CAP was judged by an expert physician review panel to be the direct cause of death in 27 of the patients, 10 with CAP having an indirect role with major contribution, 9 with CAP having an indirect role with minor contribution, and 6 with CAP having no role in death.
Do-not-resuscitate orders were present at the time of death for 21 of the patients.
Forty-five of the patients were admitted to an ICU, with 37 dying in the ICU. The eight patients who died on the ward after transfer out of the ICU had end-of-life limitations of care in place.
The researchers noted that the number of patients dying in the ICU was greater in the United States, possibly because in Europe fewer patients are admitted to an ICU.
“This discrepancy likely reflects cultural differences between the U.S. and Europe in the role of intensive care for patients with advanced age and/or advanced comorbid conditions,” they noted.
Overall, the physician review panel identified nine patients who had a lapse in quality of in-hospital CAP care, with four of the deaths potentially linked to this lapse in care.
However, two of the patients had end-of-life limitations of care in place, which according to the authors meant that “only two patients undergoing full medical treatment without end-of-life limitations of care had an identified lapse in quality of in-hospital pneumonia care potentially contributing to in-hospital death, including one with a delay in antibiotics for over an hour in the presence of shock and one with initial antibiotics not consistent with IDSA/ATS guidelines.”
The research team concluded that most in-hospital deaths among adult patients admitted with CAP in their study would not have been preventable with higher quality in-hospital pneumonia care.
“Many of the in-hospital deaths among patients admitted with CAP occurred in older patients with severe comorbidities and end-of-life limitations in care,” they noted.
They said the influence of end-of-life limitations on care short of full palliation was an important finding, with all patients who died outside the ICU having end-of-life limitations in care.
“Current diagnostic related group (DRG) and international classification of diseases (ICD) coding systems do not have the necessary nuances to capture these limitations of care, yet they are clearly important factors in determining whether patients experience in-hospital death,” they added.
Dr. Waterer reported no conflicts. Two coauthors reported potential conflicts of interest in relation to consulting fees from several pharmaceutical companies.
SOURCE: Waterer G. et al. CHEST 2018;154(3):628-35. doi: 10.1016/j.chest.2018.05.021.
Most in-hospital deaths from community-acquired pneumonia are not preventable with current medical therapy, according to an analysis of deaths at five U.S. hospitals with expertise in pneumonia care.
Adults who are hospitalized with community-acquired pneumonia (CAP) are at high risk for short-term mortality but it is unclear whether an improvement in care could lower this risk, noted the study authors led by Grant W. Waterer, MBBS, PhD, of Northwestern University, Chicago.
“Understanding the circumstances in which CAP patients die could facilitate improvements in the management of CAP by enabling future improvement efforts to focus on common preventable causes of death,” they wrote. Their report was published in CHEST®.
They therefore performed a secondary analysis of the Etiology of Pneumonia in the Community (EPIC) study involving adults hospitalized with CAP between January 2010 and June 2012 across five tertiary-care hospitals in the United States.
The clinical characteristics of patients who died in the hospital were compared with those of patients who survived to hospital discharge. Chronic heart failure, chronic obstructive pulmonary disease, coronary artery disease, chronic liver disease, cerebrovascular disease, cancer (excluding skin cancer), and diabetes were considered as severe chronic comorbidities based on their association with increased mortality and ICU admission in CAP severity scores.
Deaths caused by septic shock, respiratory failure, multisystem organ failure, cardiopulmonary arrest prior to stabilization of CAP, and endocarditis, were considered to be directly related to CAP.
Conversely, causes of death indirectly related to CAP included acute cardiovascular disease, stroke, acute renal failure, and secondary infections developed after hospitalization. Deaths caused by cancer, cirrhosis, and chronic neurologic conditions were considered unrelated to CAP.
Medical notes were assessed to determine whether the patient received management consistent with current recommendations; for example, antibiotics consistent with guidelines from the Infectious Diseases Society of America.
End-of-life limitations in care, such as patient/family decision not to proceed with full medical treatment, also were considered by the research team.
Results showed that among the 2,320 patients with radiographically confirmed CAP, 52 died during initial hospitalization, 33 of whom were aged 65 years or older, and 32 of whom had two or more chronic comorbidities.
Most of the in-hospital deaths occurred early in the hospitalization: 35 within the first 10 days of admission, and 5 after 30 days in hospital.
CAP was judged by an expert physician review panel to be the direct cause of death in 27 of the patients, 10 with CAP having an indirect role with major contribution, 9 with CAP having an indirect role with minor contribution, and 6 with CAP having no role in death.
Do-not-resuscitate orders were present at the time of death for 21 of the patients.
Forty-five of the patients were admitted to an ICU, with 37 dying in the ICU. The eight patients who died on the ward after transfer out of the ICU had end-of-life limitations of care in place.
The researchers noted that the number of patients dying in the ICU was greater in the United States, possibly because in Europe fewer patients are admitted to an ICU.
“This discrepancy likely reflects cultural differences between the U.S. and Europe in the role of intensive care for patients with advanced age and/or advanced comorbid conditions,” they noted.
Overall, the physician review panel identified nine patients who had a lapse in quality of in-hospital CAP care, with four of the deaths potentially linked to this lapse in care.
However, two of the patients had end-of-life limitations of care in place, which according to the authors meant that “only two patients undergoing full medical treatment without end-of-life limitations of care had an identified lapse in quality of in-hospital pneumonia care potentially contributing to in-hospital death, including one with a delay in antibiotics for over an hour in the presence of shock and one with initial antibiotics not consistent with IDSA/ATS guidelines.”
The research team concluded that most in-hospital deaths among adult patients admitted with CAP in their study would not have been preventable with higher quality in-hospital pneumonia care.
“Many of the in-hospital deaths among patients admitted with CAP occurred in older patients with severe comorbidities and end-of-life limitations in care,” they noted.
They said the influence of end-of-life limitations on care short of full palliation was an important finding, with all patients who died outside the ICU having end-of-life limitations in care.
“Current diagnostic related group (DRG) and international classification of diseases (ICD) coding systems do not have the necessary nuances to capture these limitations of care, yet they are clearly important factors in determining whether patients experience in-hospital death,” they added.
Dr. Waterer reported no conflicts. Two coauthors reported potential conflicts of interest in relation to consulting fees from several pharmaceutical companies.
SOURCE: Waterer G. et al. CHEST 2018;154(3):628-35. doi: 10.1016/j.chest.2018.05.021.
FROM CHEST
Key clinical point: Most in-hospital deaths from community-acquired pneumonia are not preventable with current medical therapy.
Major finding: Two out of 52 patients who died in-hospital from community-acquired pneumonia (CAP) who were undergoing full medical treatment without end-of-life limitations of care had an identified lapse in quality of in-hospital pneumonia care that potentially contributed to their death.
Study details: A secondary analysis of the prospective multicenter Etiology of Pneumonia in the Community (EPIC) study involving 2,320 adults with radiographically confirmed CAP.
Disclosures: Dr. Waterer reported no conflicts. Two coauthors reported potential conflicts of interest in relation to consulting fees from several pharmaceutical companies.
Source: Waterer G. et al. CHEST 2018;154(3):628-35.
New perspectives keep SHM relevant
Atashi Mandal, MD, finds committee work illuminating and gratifying
Editor’s note: SHM occasionally puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.
This month, The Hospitalist spotlights Atashi Mandal, MD , a Med-Peds hospitalist in Huntington Beach, Calif. Dr. Mandal has been a member of SHM since for more than a decade, has served on the Public Policy Committee, and is currently serving on the Patient Experience Committee. 
How did you initially hear about SHM, and why did you become a member?
I was a newly minted hospitalist and eagerly searching for a way to use my CME allowance, when I discovered SHM’s annual conference, which happened to be nearby in San Diego that year. I also was intrigued by, and excited to learn more about, an organization that dedicated itself only to hospital medicine. After attending the conference, I was hooked!
As a member of more than a decade, what aspects of your membership have you found to be most valuable?
I’ve always been very impressed by the quality and variety of the educational offerings. As a Med-Peds hospitalist, I can happily attest to greater inclusion of pediatric-specific content and a more robust presence of pediatric hospitalists over the years. Moreover, I am very appreciative of SHM’s progressive attitude as demonstrated by incorporating topics such as gender disparities, LGBTQ health, and the opioid crisis into our curriculum. I also have greatly enjoyed the networking opportunities with fellow hospitalists, some of whom I am happy to say have also become good friends over the years. More recently over the past few years, I’ve participated on committees, which has been an illuminating and gratifying way to help shape SHM’s current and future directives.
Describe your role on the Public Policy Committee. What did the committee accomplish during your term?
I was very honored to serve as a member of this committee for three terms. The staff is truly superhuman and amazing, considering how well they stay abreast of the swiftly changing administrative and legislative currents in health care. Just during my tenure as an SHM member, we’ve witnessed paramount shifts in our practice and culture, from the passage of MACRA, [the Medicare Access and CHIP Reauthorization Act] to the opioid epidemic. The Public Policy Committee identifies issues that affect our practice as hospitalists and advocates on our behalf through various means, from submitting comments and letters as well as personally meeting with our regulatory agencies such as CMS [Centers for Medicare & Medicaid Services], and our federal legislators. Some major victories were the acquisition of our specialty billing code and approval of an advanced care billing code. Additionally, the committee has been tirelessly advocating for reform with observation status. We have submitted comments to legislative committees regarding the opioid crisis and continue to work with MACRA as it affects our membership. While I served, I took a special interest in mental health and pediatric issues, including CHIP [Children’s Health Insurance Program] reauthorization and the 21st Century Cures Act.
What is Hill Day, and what can Hospital Medicine 2019 attendees expect to gain from participating?
Hill Day is a truly educational, exciting – and most important – fun opportunity to hone our advocacy skills and gain some real-world experience interacting with legislators and their staffs. On the last day of the annual conference attendees can travel to D.C., where we will spend about a half-day meeting with our respective state’s legislators or their staff. We typically discuss two or three preselected bills that can directly impact our practice as hospitalists. The legislators and their staffers generally are not aware of how certain legislative items can greatly benefit or adversely affect our patients, and they therefore rely on front-line clinicians like us to provide this narrative, much to their gratitude. I learn a lot and have even more fun each time I go to Capitol Hill, so I strongly encourage everyone to participate in this unique opportunity.
Do you have any advice for early-career hospitalists looking to gain experience and get involved with SHM?
I would encourage you to find your voice and participate! Whether by joining a committee or a Special Interest Group or just chatting on one of the many stimulating forums, we each have something to bring to the table, irrespective of our tenure as hospitalists. The new perspectives mingling with those that are well established is what keeps our organization relevant, so I look forward to new ideas and fresh faces!
Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.
Atashi Mandal, MD, finds committee work illuminating and gratifying
Atashi Mandal, MD, finds committee work illuminating and gratifying
Editor’s note: SHM occasionally puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.
This month, The Hospitalist spotlights Atashi Mandal, MD , a Med-Peds hospitalist in Huntington Beach, Calif. Dr. Mandal has been a member of SHM since for more than a decade, has served on the Public Policy Committee, and is currently serving on the Patient Experience Committee.
How did you initially hear about SHM, and why did you become a member?
I was a newly minted hospitalist and eagerly searching for a way to use my CME allowance, when I discovered SHM’s annual conference, which happened to be nearby in San Diego that year. I also was intrigued by, and excited to learn more about, an organization that dedicated itself only to hospital medicine. After attending the conference, I was hooked!
As a member of more than a decade, what aspects of your membership have you found to be most valuable?
I’ve always been very impressed by the quality and variety of the educational offerings. As a Med-Peds hospitalist, I can happily attest to greater inclusion of pediatric-specific content and a more robust presence of pediatric hospitalists over the years. Moreover, I am very appreciative of SHM’s progressive attitude as demonstrated by incorporating topics such as gender disparities, LGBTQ health, and the opioid crisis into our curriculum. I also have greatly enjoyed the networking opportunities with fellow hospitalists, some of whom I am happy to say have also become good friends over the years. More recently over the past few years, I’ve participated on committees, which has been an illuminating and gratifying way to help shape SHM’s current and future directives.
Describe your role on the Public Policy Committee. What did the committee accomplish during your term?
I was very honored to serve as a member of this committee for three terms. The staff is truly superhuman and amazing, considering how well they stay abreast of the swiftly changing administrative and legislative currents in health care. Just during my tenure as an SHM member, we’ve witnessed paramount shifts in our practice and culture, from the passage of MACRA, [the Medicare Access and CHIP Reauthorization Act] to the opioid epidemic. The Public Policy Committee identifies issues that affect our practice as hospitalists and advocates on our behalf through various means, from submitting comments and letters as well as personally meeting with our regulatory agencies such as CMS [Centers for Medicare & Medicaid Services], and our federal legislators. Some major victories were the acquisition of our specialty billing code and approval of an advanced care billing code. Additionally, the committee has been tirelessly advocating for reform with observation status. We have submitted comments to legislative committees regarding the opioid crisis and continue to work with MACRA as it affects our membership. While I served, I took a special interest in mental health and pediatric issues, including CHIP [Children’s Health Insurance Program] reauthorization and the 21st Century Cures Act.
What is Hill Day, and what can Hospital Medicine 2019 attendees expect to gain from participating?
Hill Day is a truly educational, exciting – and most important – fun opportunity to hone our advocacy skills and gain some real-world experience interacting with legislators and their staffs. On the last day of the annual conference attendees can travel to D.C., where we will spend about a half-day meeting with our respective state’s legislators or their staff. We typically discuss two or three preselected bills that can directly impact our practice as hospitalists. The legislators and their staffers generally are not aware of how certain legislative items can greatly benefit or adversely affect our patients, and they therefore rely on front-line clinicians like us to provide this narrative, much to their gratitude. I learn a lot and have even more fun each time I go to Capitol Hill, so I strongly encourage everyone to participate in this unique opportunity.
Do you have any advice for early-career hospitalists looking to gain experience and get involved with SHM?
I would encourage you to find your voice and participate! Whether by joining a committee or a Special Interest Group or just chatting on one of the many stimulating forums, we each have something to bring to the table, irrespective of our tenure as hospitalists. The new perspectives mingling with those that are well established is what keeps our organization relevant, so I look forward to new ideas and fresh faces!
Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: SHM occasionally puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.
This month, The Hospitalist spotlights Atashi Mandal, MD , a Med-Peds hospitalist in Huntington Beach, Calif. Dr. Mandal has been a member of SHM since for more than a decade, has served on the Public Policy Committee, and is currently serving on the Patient Experience Committee.
How did you initially hear about SHM, and why did you become a member?
I was a newly minted hospitalist and eagerly searching for a way to use my CME allowance, when I discovered SHM’s annual conference, which happened to be nearby in San Diego that year. I also was intrigued by, and excited to learn more about, an organization that dedicated itself only to hospital medicine. After attending the conference, I was hooked!
As a member of more than a decade, what aspects of your membership have you found to be most valuable?
I’ve always been very impressed by the quality and variety of the educational offerings. As a Med-Peds hospitalist, I can happily attest to greater inclusion of pediatric-specific content and a more robust presence of pediatric hospitalists over the years. Moreover, I am very appreciative of SHM’s progressive attitude as demonstrated by incorporating topics such as gender disparities, LGBTQ health, and the opioid crisis into our curriculum. I also have greatly enjoyed the networking opportunities with fellow hospitalists, some of whom I am happy to say have also become good friends over the years. More recently over the past few years, I’ve participated on committees, which has been an illuminating and gratifying way to help shape SHM’s current and future directives.
Describe your role on the Public Policy Committee. What did the committee accomplish during your term?
I was very honored to serve as a member of this committee for three terms. The staff is truly superhuman and amazing, considering how well they stay abreast of the swiftly changing administrative and legislative currents in health care. Just during my tenure as an SHM member, we’ve witnessed paramount shifts in our practice and culture, from the passage of MACRA, [the Medicare Access and CHIP Reauthorization Act] to the opioid epidemic. The Public Policy Committee identifies issues that affect our practice as hospitalists and advocates on our behalf through various means, from submitting comments and letters as well as personally meeting with our regulatory agencies such as CMS [Centers for Medicare & Medicaid Services], and our federal legislators. Some major victories were the acquisition of our specialty billing code and approval of an advanced care billing code. Additionally, the committee has been tirelessly advocating for reform with observation status. We have submitted comments to legislative committees regarding the opioid crisis and continue to work with MACRA as it affects our membership. While I served, I took a special interest in mental health and pediatric issues, including CHIP [Children’s Health Insurance Program] reauthorization and the 21st Century Cures Act.
What is Hill Day, and what can Hospital Medicine 2019 attendees expect to gain from participating?
Hill Day is a truly educational, exciting – and most important – fun opportunity to hone our advocacy skills and gain some real-world experience interacting with legislators and their staffs. On the last day of the annual conference attendees can travel to D.C., where we will spend about a half-day meeting with our respective state’s legislators or their staff. We typically discuss two or three preselected bills that can directly impact our practice as hospitalists. The legislators and their staffers generally are not aware of how certain legislative items can greatly benefit or adversely affect our patients, and they therefore rely on front-line clinicians like us to provide this narrative, much to their gratitude. I learn a lot and have even more fun each time I go to Capitol Hill, so I strongly encourage everyone to participate in this unique opportunity.
Do you have any advice for early-career hospitalists looking to gain experience and get involved with SHM?
I would encourage you to find your voice and participate! Whether by joining a committee or a Special Interest Group or just chatting on one of the many stimulating forums, we each have something to bring to the table, irrespective of our tenure as hospitalists. The new perspectives mingling with those that are well established is what keeps our organization relevant, so I look forward to new ideas and fresh faces!
Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.
Guideline offers comprehensive approach for ICU clinicians
A new (PADIS).
The guideline builds upon the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) in Adult Patients in the ICU. Given the comprehensive nature of the PADIS guideline, an accompanying commentary was published simultaneously to help with implementation and interpretation. Both papers are the result of a large-scale, multicenter collaboration and were published in Critical Care Medicine.
A panel of 32 international experts, four methodologists, and four survivors of critical illness used the Grading of Recommendations Assessment, Development and Evaluation approach to develop the PADIS guideline.
“Thousands of hours were invested by these guidelines’ authors, who were in turn were supported by formal and informal collaborators, over the 3.5 years it took to produce this effort,” reported lead author John W. Devlin, PharmD, of the department of pharmacy and health systems sciences, Bouvé College of Health Sciences at Northeastern University, Boston, and his colleagues.
Compared with the 2013 PAD guideline, the PADIS guideline includes new sections regarding rehabilitation/mobility and sleep. “We sought to clarify conceptual definitions within these relatively new critical care research domains,” the panel wrote. “The recommendation rationales, fueled by debate and discussion, circled back to the bedside experience – and the perspective of what was best for patients – held by all panelists and methodology experts.”
The result is extensive and comprehensive, consisting of both broad and specific descriptions of current ICU practices and associated evidence; the guideline includes 37 recommendations, 32 ungraded, nonactionable statements, and two good practice statements. Of note, conditional recommendations far outnumber strong recommendations (34 vs. 3). Reasons for conditional rather than strong recommendations are discussed in rationale sections within the guideline and in the accompanying paper.
“Although our goal was to provide specific recommendations for each question, we suspect some guideline readers may be discouraged by the conditional nature of many recommendations and daunted by the breadth of topics discussed,” wrote Michele C. Balas, PhD, of the Ohio State University College of Nursing in Columbus, and her colleagues. Dr. Balas was on the guideline panel and is the lead author of the accompanying article intended to facilitate implementation and interpretation.
One of the more challenging recommendations surrounds the use of antipsychotics for delirious patients. Although this intervention has become relatively common, the guideline stands against it.
“It should be emphasized that there are few supportive data on ICU antipsychotic use and that the initiation of psychoactive medications during critical illness often results in their inappropriate continuation after ICU discharge,” wrote Dr. Balas and her coauthors.
Along with a hard look at existing practices, the panel actively sought to expand upon the 2013 guideline with new interventions. Discussions ranged from the less conventional, such as aromatherapy, to the more established, such as polypharmacy. Questions, recommendations, and rationale are clearly described for each topic, with clear supporting evidence. Where evidence is missing, the panel recommends future research possibilities.
“One example is the consideration of multiple pharmacologic and nonpharmacologic coanalgesic approaches to the ICU patient,” wrote Dr. Devlin and his coauthors. “When the published evidence was insufficient, limited to a narrow population or specific intervention (e.g., for procedural analgesia), or outright absent to answer the questions we posed, we structured evidence gap descriptors to inform clinicians where the uncertainty lay, and intended to provide sufficient information to apprise and invite researchers to address these gaps.”
The authors disclosed funding from AstraZeneca, Baxter, Covidien, and others.
SOURCE: Devlin JW et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003299; Balas MC et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003307.
A new (PADIS).
The guideline builds upon the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) in Adult Patients in the ICU. Given the comprehensive nature of the PADIS guideline, an accompanying commentary was published simultaneously to help with implementation and interpretation. Both papers are the result of a large-scale, multicenter collaboration and were published in Critical Care Medicine.
A panel of 32 international experts, four methodologists, and four survivors of critical illness used the Grading of Recommendations Assessment, Development and Evaluation approach to develop the PADIS guideline.
“Thousands of hours were invested by these guidelines’ authors, who were in turn were supported by formal and informal collaborators, over the 3.5 years it took to produce this effort,” reported lead author John W. Devlin, PharmD, of the department of pharmacy and health systems sciences, Bouvé College of Health Sciences at Northeastern University, Boston, and his colleagues.
Compared with the 2013 PAD guideline, the PADIS guideline includes new sections regarding rehabilitation/mobility and sleep. “We sought to clarify conceptual definitions within these relatively new critical care research domains,” the panel wrote. “The recommendation rationales, fueled by debate and discussion, circled back to the bedside experience – and the perspective of what was best for patients – held by all panelists and methodology experts.”
The result is extensive and comprehensive, consisting of both broad and specific descriptions of current ICU practices and associated evidence; the guideline includes 37 recommendations, 32 ungraded, nonactionable statements, and two good practice statements. Of note, conditional recommendations far outnumber strong recommendations (34 vs. 3). Reasons for conditional rather than strong recommendations are discussed in rationale sections within the guideline and in the accompanying paper.
“Although our goal was to provide specific recommendations for each question, we suspect some guideline readers may be discouraged by the conditional nature of many recommendations and daunted by the breadth of topics discussed,” wrote Michele C. Balas, PhD, of the Ohio State University College of Nursing in Columbus, and her colleagues. Dr. Balas was on the guideline panel and is the lead author of the accompanying article intended to facilitate implementation and interpretation.
One of the more challenging recommendations surrounds the use of antipsychotics for delirious patients. Although this intervention has become relatively common, the guideline stands against it.
“It should be emphasized that there are few supportive data on ICU antipsychotic use and that the initiation of psychoactive medications during critical illness often results in their inappropriate continuation after ICU discharge,” wrote Dr. Balas and her coauthors.
Along with a hard look at existing practices, the panel actively sought to expand upon the 2013 guideline with new interventions. Discussions ranged from the less conventional, such as aromatherapy, to the more established, such as polypharmacy. Questions, recommendations, and rationale are clearly described for each topic, with clear supporting evidence. Where evidence is missing, the panel recommends future research possibilities.
“One example is the consideration of multiple pharmacologic and nonpharmacologic coanalgesic approaches to the ICU patient,” wrote Dr. Devlin and his coauthors. “When the published evidence was insufficient, limited to a narrow population or specific intervention (e.g., for procedural analgesia), or outright absent to answer the questions we posed, we structured evidence gap descriptors to inform clinicians where the uncertainty lay, and intended to provide sufficient information to apprise and invite researchers to address these gaps.”
The authors disclosed funding from AstraZeneca, Baxter, Covidien, and others.
SOURCE: Devlin JW et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003299; Balas MC et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003307.
A new (PADIS).
The guideline builds upon the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) in Adult Patients in the ICU. Given the comprehensive nature of the PADIS guideline, an accompanying commentary was published simultaneously to help with implementation and interpretation. Both papers are the result of a large-scale, multicenter collaboration and were published in Critical Care Medicine.
A panel of 32 international experts, four methodologists, and four survivors of critical illness used the Grading of Recommendations Assessment, Development and Evaluation approach to develop the PADIS guideline.
“Thousands of hours were invested by these guidelines’ authors, who were in turn were supported by formal and informal collaborators, over the 3.5 years it took to produce this effort,” reported lead author John W. Devlin, PharmD, of the department of pharmacy and health systems sciences, Bouvé College of Health Sciences at Northeastern University, Boston, and his colleagues.
Compared with the 2013 PAD guideline, the PADIS guideline includes new sections regarding rehabilitation/mobility and sleep. “We sought to clarify conceptual definitions within these relatively new critical care research domains,” the panel wrote. “The recommendation rationales, fueled by debate and discussion, circled back to the bedside experience – and the perspective of what was best for patients – held by all panelists and methodology experts.”
The result is extensive and comprehensive, consisting of both broad and specific descriptions of current ICU practices and associated evidence; the guideline includes 37 recommendations, 32 ungraded, nonactionable statements, and two good practice statements. Of note, conditional recommendations far outnumber strong recommendations (34 vs. 3). Reasons for conditional rather than strong recommendations are discussed in rationale sections within the guideline and in the accompanying paper.
“Although our goal was to provide specific recommendations for each question, we suspect some guideline readers may be discouraged by the conditional nature of many recommendations and daunted by the breadth of topics discussed,” wrote Michele C. Balas, PhD, of the Ohio State University College of Nursing in Columbus, and her colleagues. Dr. Balas was on the guideline panel and is the lead author of the accompanying article intended to facilitate implementation and interpretation.
One of the more challenging recommendations surrounds the use of antipsychotics for delirious patients. Although this intervention has become relatively common, the guideline stands against it.
“It should be emphasized that there are few supportive data on ICU antipsychotic use and that the initiation of psychoactive medications during critical illness often results in their inappropriate continuation after ICU discharge,” wrote Dr. Balas and her coauthors.
Along with a hard look at existing practices, the panel actively sought to expand upon the 2013 guideline with new interventions. Discussions ranged from the less conventional, such as aromatherapy, to the more established, such as polypharmacy. Questions, recommendations, and rationale are clearly described for each topic, with clear supporting evidence. Where evidence is missing, the panel recommends future research possibilities.
“One example is the consideration of multiple pharmacologic and nonpharmacologic coanalgesic approaches to the ICU patient,” wrote Dr. Devlin and his coauthors. “When the published evidence was insufficient, limited to a narrow population or specific intervention (e.g., for procedural analgesia), or outright absent to answer the questions we posed, we structured evidence gap descriptors to inform clinicians where the uncertainty lay, and intended to provide sufficient information to apprise and invite researchers to address these gaps.”
The authors disclosed funding from AstraZeneca, Baxter, Covidien, and others.
SOURCE: Devlin JW et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003299; Balas MC et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003307.
FROM CRITICAL CARE MEDICINE
Key clinical point: The 2018 PADIS guideline recommends intervention strategies for adult ICU patients with pain, agitation/sedation, delirium, immobility, and sleep disruption.
Major finding: The guideline includes 37 recommendations; 32 ungraded, nonactionable statements; and two good practice statements.
Study details: A clinical practice guideline was created by 32 international experts, four methodologists, and four survivors of critical illness.
Disclosures: The authors declared funding from AstraZeneca, Baxter, Covidien, and others.
Sources: Devlin JW et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003299; Balas MC et al. Crit Care Med. 2018 Sep 1. doi: 10.1097/CCM.0000000000003307.
Expert panel updates guidelines on antithrombotic therapy for AF
For patients with , experts said in a comprehensive, updated guideline.
The 113-page guideline, published in the journal CHEST®, provides antithrombotic treatment recommendations for atrial fibrillation based on different levels of risk for stroke and in a variety of clinical presentations.
Altogether, the new guidelines highlight 60 key recommendations from the 12-person expert panel, chaired by Gregory Y.H. Lip, MD, of the Institute of Cardiovascular Sciences, University of Birmingham (England).
To develop the guidelines, the panel conducted a systematic literature review of relevant articles released since the 2012 publication of Thrombolytic Therapy: American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines (9th Edition).
Since that time, “there have been substantial developments in atrial fibrillation thromboprophylaxis, whether with regard to risk assessment, antithrombotic drugs, or non-drug approaches,” panelists said in their report.
The panel graded the quality of the new evidence found in the literature review, and then undertook a consensus development process. Each recommendation and statement required at least 80% consensus to pass.
Their treatment recommendations in the report are focused on three topic areas: stroke and bleeding risk assessment, antithrombotic therapy in general, and antithrombotic therapy in special situations, such as acute coronary syndrome and stenting, chronic atrial flutter, pregnancy, and chronic kidney disease.
Stroke prevention is the main priority in a “holistic approach” to management of atrial fibrillation, the panelists said in the report.
“Many of the risk factors leading to incident AF are also risk factors for ischemic stroke, and the promotion of an integrated or holistic approach to AF management is needed, incorporating stroke prevention, addressing symptoms and risk factor management,” they said.
No antithrombotic therapy is needed for patients who have atrial fibrillation without valvular heart disease, the panelists concluded.
For patients with at least one nongender CHA2DS2-VASc stroke risk factor, oral anticoagulation is recommended over aspirin, aspirin and clopidogrel, or no therapy, they said.
In high-risk patients, including males with two or more CHA2DS2-VASc risk factors and females with three or more, novel oral anticoagulants are recommended over adjusted-dose warfarin, they added.
At each patient contact, patients with atrial fibrillation should receive bleeding risk assessment starting with potentially modifiable risk factors such as uncontrolled blood pressure or excessive alcohol intake, according to the expert panel.
High-risk patients, as indicated by a HAS-BLED score of 3 or greater, should have more frequent and regular follow-up, they said.
The expert panel report concludes with a discussion on practical and patient-centered issues.
“Patient education is essential to provide patients with sufficient information to enable them to make an informed decision about whether or not they wish to take oral anticoagulants, and if they do, which oral anticoagulant they would prefer,” Dr. Lip and his colleagues said in their report.
Dr. Lip disclosed a potential conflict of interest with Boehringer Ingelheim. Expert panel members reported disclosures related to Boston Scientific, Medtronic, St. Jude Medical, Biotronik, MSD, Novartis, Pfizer, Bayer, Servier, Gilead, Bristol-Myers Squibb, AstraZeneca, and others.
SOURCE: Lip GYH et al. CHEST. 2018 Aug 21. pii: S0012-3692(18)32244-X.
For patients with , experts said in a comprehensive, updated guideline.
The 113-page guideline, published in the journal CHEST®, provides antithrombotic treatment recommendations for atrial fibrillation based on different levels of risk for stroke and in a variety of clinical presentations.
Altogether, the new guidelines highlight 60 key recommendations from the 12-person expert panel, chaired by Gregory Y.H. Lip, MD, of the Institute of Cardiovascular Sciences, University of Birmingham (England).
To develop the guidelines, the panel conducted a systematic literature review of relevant articles released since the 2012 publication of Thrombolytic Therapy: American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines (9th Edition).
Since that time, “there have been substantial developments in atrial fibrillation thromboprophylaxis, whether with regard to risk assessment, antithrombotic drugs, or non-drug approaches,” panelists said in their report.
The panel graded the quality of the new evidence found in the literature review, and then undertook a consensus development process. Each recommendation and statement required at least 80% consensus to pass.
Their treatment recommendations in the report are focused on three topic areas: stroke and bleeding risk assessment, antithrombotic therapy in general, and antithrombotic therapy in special situations, such as acute coronary syndrome and stenting, chronic atrial flutter, pregnancy, and chronic kidney disease.
Stroke prevention is the main priority in a “holistic approach” to management of atrial fibrillation, the panelists said in the report.
“Many of the risk factors leading to incident AF are also risk factors for ischemic stroke, and the promotion of an integrated or holistic approach to AF management is needed, incorporating stroke prevention, addressing symptoms and risk factor management,” they said.
No antithrombotic therapy is needed for patients who have atrial fibrillation without valvular heart disease, the panelists concluded.
For patients with at least one nongender CHA2DS2-VASc stroke risk factor, oral anticoagulation is recommended over aspirin, aspirin and clopidogrel, or no therapy, they said.
In high-risk patients, including males with two or more CHA2DS2-VASc risk factors and females with three or more, novel oral anticoagulants are recommended over adjusted-dose warfarin, they added.
At each patient contact, patients with atrial fibrillation should receive bleeding risk assessment starting with potentially modifiable risk factors such as uncontrolled blood pressure or excessive alcohol intake, according to the expert panel.
High-risk patients, as indicated by a HAS-BLED score of 3 or greater, should have more frequent and regular follow-up, they said.
The expert panel report concludes with a discussion on practical and patient-centered issues.
“Patient education is essential to provide patients with sufficient information to enable them to make an informed decision about whether or not they wish to take oral anticoagulants, and if they do, which oral anticoagulant they would prefer,” Dr. Lip and his colleagues said in their report.
Dr. Lip disclosed a potential conflict of interest with Boehringer Ingelheim. Expert panel members reported disclosures related to Boston Scientific, Medtronic, St. Jude Medical, Biotronik, MSD, Novartis, Pfizer, Bayer, Servier, Gilead, Bristol-Myers Squibb, AstraZeneca, and others.
SOURCE: Lip GYH et al. CHEST. 2018 Aug 21. pii: S0012-3692(18)32244-X.
For patients with , experts said in a comprehensive, updated guideline.
The 113-page guideline, published in the journal CHEST®, provides antithrombotic treatment recommendations for atrial fibrillation based on different levels of risk for stroke and in a variety of clinical presentations.
Altogether, the new guidelines highlight 60 key recommendations from the 12-person expert panel, chaired by Gregory Y.H. Lip, MD, of the Institute of Cardiovascular Sciences, University of Birmingham (England).
To develop the guidelines, the panel conducted a systematic literature review of relevant articles released since the 2012 publication of Thrombolytic Therapy: American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines (9th Edition).
Since that time, “there have been substantial developments in atrial fibrillation thromboprophylaxis, whether with regard to risk assessment, antithrombotic drugs, or non-drug approaches,” panelists said in their report.
The panel graded the quality of the new evidence found in the literature review, and then undertook a consensus development process. Each recommendation and statement required at least 80% consensus to pass.
Their treatment recommendations in the report are focused on three topic areas: stroke and bleeding risk assessment, antithrombotic therapy in general, and antithrombotic therapy in special situations, such as acute coronary syndrome and stenting, chronic atrial flutter, pregnancy, and chronic kidney disease.
Stroke prevention is the main priority in a “holistic approach” to management of atrial fibrillation, the panelists said in the report.
“Many of the risk factors leading to incident AF are also risk factors for ischemic stroke, and the promotion of an integrated or holistic approach to AF management is needed, incorporating stroke prevention, addressing symptoms and risk factor management,” they said.
No antithrombotic therapy is needed for patients who have atrial fibrillation without valvular heart disease, the panelists concluded.
For patients with at least one nongender CHA2DS2-VASc stroke risk factor, oral anticoagulation is recommended over aspirin, aspirin and clopidogrel, or no therapy, they said.
In high-risk patients, including males with two or more CHA2DS2-VASc risk factors and females with three or more, novel oral anticoagulants are recommended over adjusted-dose warfarin, they added.
At each patient contact, patients with atrial fibrillation should receive bleeding risk assessment starting with potentially modifiable risk factors such as uncontrolled blood pressure or excessive alcohol intake, according to the expert panel.
High-risk patients, as indicated by a HAS-BLED score of 3 or greater, should have more frequent and regular follow-up, they said.
The expert panel report concludes with a discussion on practical and patient-centered issues.
“Patient education is essential to provide patients with sufficient information to enable them to make an informed decision about whether or not they wish to take oral anticoagulants, and if they do, which oral anticoagulant they would prefer,” Dr. Lip and his colleagues said in their report.
Dr. Lip disclosed a potential conflict of interest with Boehringer Ingelheim. Expert panel members reported disclosures related to Boston Scientific, Medtronic, St. Jude Medical, Biotronik, MSD, Novartis, Pfizer, Bayer, Servier, Gilead, Bristol-Myers Squibb, AstraZeneca, and others.
SOURCE: Lip GYH et al. CHEST. 2018 Aug 21. pii: S0012-3692(18)32244-X.
FROM CHEST
White coats and provider attire: Does it matter to patients?
What is appropriate “ward garb”?
The question of appropriate ward garb is a problem for the ages. Compared with photo stills and films from the 1960s, the doctors of today appear like vagabonds. No ties, no lab coats, and scrub tops have become the norm for a number (a majority?) of hospital-based docs – and even more so on the surgical wards and in the ER.
Past studies have addressed patient preferences for provider dress, but none like the results of a recent survey.
From the University of Michigan, Ann Arbor, comes a physician attire survey of a convenience sample of 4,000 patients at 10 U.S. academic medical centers. It included both inpatients and outpatients, and used the design of many previous studies, showing patients the same doctor dressed seven different ways. After viewing the photographs, the patients received surveys as to their preference of physician based on attire, as well as being asked to rate the physician in the areas of knowledge, trust, care, approachability, and comfort.
You can see the domains: casual, scrubs, and formal, each with and without a lab coat. The seventh category is business attire (future C-suite wannabes – you know who you are).
Over half of the participants indicated that how a physician dresses was important to them, with more than one in three stating that this influenced how happy they were with care received. Overall, respondents indicated that formal attire with white coats was the most preferred form of physician dress.
I found the discussion in the study worthwhile, along with the strengths and weaknesses of the author’s outline. They went to great lengths to design a nonbiased questionnaire and used a consistent approach to shooting their photos. They also discussed lab coats, long sleeves, and hygiene.
But what to draw from the findings? Does patient satisfaction matter or just clinical outcomes? Is patient happiness a means to an end or an end unto itself? Can I even get you exercised about a score of 6 versus 8 (a 25% difference)? For instance, imagine the worst-dressed doc – say shorts and flip-flops. Is that a 5.8 or a 2.3? The anchor matters, and it helps to put the ratings in context.
Read the full post at hospitalleader.org.
Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He is a founding member of the Society of Hospital Medicine and served as a board member and officer.
Also in The Hospital Leader
•Hospitalists Can Improve Patient Trust…in Their Colleagues by Chris Moriates, MD, SFHM
•Treatment of Type II MIs by Brad Flansbaum, MD, MPH, MHM
•The $64,000 Question: How Can Hospitalists Improve Their HCAHPS Scores? by Leslie Flores, MHA, SFHM
What is appropriate “ward garb”?
What is appropriate “ward garb”?
The question of appropriate ward garb is a problem for the ages. Compared with photo stills and films from the 1960s, the doctors of today appear like vagabonds. No ties, no lab coats, and scrub tops have become the norm for a number (a majority?) of hospital-based docs – and even more so on the surgical wards and in the ER.
Past studies have addressed patient preferences for provider dress, but none like the results of a recent survey.
From the University of Michigan, Ann Arbor, comes a physician attire survey of a convenience sample of 4,000 patients at 10 U.S. academic medical centers. It included both inpatients and outpatients, and used the design of many previous studies, showing patients the same doctor dressed seven different ways. After viewing the photographs, the patients received surveys as to their preference of physician based on attire, as well as being asked to rate the physician in the areas of knowledge, trust, care, approachability, and comfort.
You can see the domains: casual, scrubs, and formal, each with and without a lab coat. The seventh category is business attire (future C-suite wannabes – you know who you are).
Over half of the participants indicated that how a physician dresses was important to them, with more than one in three stating that this influenced how happy they were with care received. Overall, respondents indicated that formal attire with white coats was the most preferred form of physician dress.
I found the discussion in the study worthwhile, along with the strengths and weaknesses of the author’s outline. They went to great lengths to design a nonbiased questionnaire and used a consistent approach to shooting their photos. They also discussed lab coats, long sleeves, and hygiene.
But what to draw from the findings? Does patient satisfaction matter or just clinical outcomes? Is patient happiness a means to an end or an end unto itself? Can I even get you exercised about a score of 6 versus 8 (a 25% difference)? For instance, imagine the worst-dressed doc – say shorts and flip-flops. Is that a 5.8 or a 2.3? The anchor matters, and it helps to put the ratings in context.
Read the full post at hospitalleader.org.
Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He is a founding member of the Society of Hospital Medicine and served as a board member and officer.
Also in The Hospital Leader
•Hospitalists Can Improve Patient Trust…in Their Colleagues by Chris Moriates, MD, SFHM
•Treatment of Type II MIs by Brad Flansbaum, MD, MPH, MHM
•The $64,000 Question: How Can Hospitalists Improve Their HCAHPS Scores? by Leslie Flores, MHA, SFHM
The question of appropriate ward garb is a problem for the ages. Compared with photo stills and films from the 1960s, the doctors of today appear like vagabonds. No ties, no lab coats, and scrub tops have become the norm for a number (a majority?) of hospital-based docs – and even more so on the surgical wards and in the ER.
Past studies have addressed patient preferences for provider dress, but none like the results of a recent survey.
From the University of Michigan, Ann Arbor, comes a physician attire survey of a convenience sample of 4,000 patients at 10 U.S. academic medical centers. It included both inpatients and outpatients, and used the design of many previous studies, showing patients the same doctor dressed seven different ways. After viewing the photographs, the patients received surveys as to their preference of physician based on attire, as well as being asked to rate the physician in the areas of knowledge, trust, care, approachability, and comfort.
You can see the domains: casual, scrubs, and formal, each with and without a lab coat. The seventh category is business attire (future C-suite wannabes – you know who you are).
Over half of the participants indicated that how a physician dresses was important to them, with more than one in three stating that this influenced how happy they were with care received. Overall, respondents indicated that formal attire with white coats was the most preferred form of physician dress.
I found the discussion in the study worthwhile, along with the strengths and weaknesses of the author’s outline. They went to great lengths to design a nonbiased questionnaire and used a consistent approach to shooting their photos. They also discussed lab coats, long sleeves, and hygiene.
But what to draw from the findings? Does patient satisfaction matter or just clinical outcomes? Is patient happiness a means to an end or an end unto itself? Can I even get you exercised about a score of 6 versus 8 (a 25% difference)? For instance, imagine the worst-dressed doc – say shorts and flip-flops. Is that a 5.8 or a 2.3? The anchor matters, and it helps to put the ratings in context.
Read the full post at hospitalleader.org.
Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He is a founding member of the Society of Hospital Medicine and served as a board member and officer.
Also in The Hospital Leader
•Hospitalists Can Improve Patient Trust…in Their Colleagues by Chris Moriates, MD, SFHM
•Treatment of Type II MIs by Brad Flansbaum, MD, MPH, MHM
•The $64,000 Question: How Can Hospitalists Improve Their HCAHPS Scores? by Leslie Flores, MHA, SFHM
Hospitalist movers and shakers – Sept. 2018
Modern Healthcare recently announced its list of the 50 Most Influential Physician Executives and Leaders, and hospital medicine was well represented among the honorees. The honored physicians were selected by a panel of experts and peers for their leadership and impact on the profession.
Topping the list was Scott Gottlieb, MD, the commissioner of the Food and Drug Administration. Dr. Gottlieb was confirmed to his position in May 2017 and, in his first year, has focused on price transparency and the approval of generic medications.
Dr. Gottlieb was deputy commissioner of the FDA from 2005-2007, and he has worked as an advisor and analyst for GlaxoSmithKline, the American Enterprise Institute, Vertex Pharmaceuticals, and Avilene Health.
Dr. Gottlieb earned his medical degree from the Icahn School of Medicine at Mount Sinai, New York, and completed his residency at Mount Sinai Hospital. He has worked as a hospitalist at New York University’s Tisch Hospital, the Hospital for Joint Diseases, and Stamford (Conn.) Hospital.
Patrick Conway, MD, was listed at number 23 on Modern Healthcare’s 50 Most Influential Physician Executives and Leaders. Formerly the deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services, Dr. Conway recently became president and chief executive officer of Blue Cross and Blue Shield of North Carolina.
Dr. Conway is known for his ability to develop and promote alternative payment models. He was elected to the National Academy of Medicine’s Institute of Medicine in 2014 and was selected as a Master of Hospital Medicine by the Society of Hospital Medicine.
Lynn Massingale, MD, the cofounder and chairman of TeamHealth, was named one of the 50 Most Influential Physician Executives and Leaders for a third year running, coming in at number 27 on the list. Dr. Massingale, who also recently was named to the Tennessee Healthcare Hall of Fame, founded TeamHealth in 1979 and was its chief executive officer for 30 years before assuming the role of chairman in 2008.
TeamHealth provides outsourced emergency medicine, hospitalist, critical care, anesthesiology, and acute care surgery services, among other specialties, at more than 3,200 facilities and physician groups across the United States.
Veeravat Taecharvongphairoj, MD, a veteran internist and hospitalist at Hemet Valley Medical Center in Hemet, Calif., has been honored by the International Association of Healthcare Professionals in its Leading Physicians of the World publication.
Dr. Taecharvongphairoj completed his residency at the University of Hawaii, Honolulu, before accepting a fellowship in hospital and palliative care at Cedars-Sinai Medical Center, Los Angeles. He is a member of the American Academy of Hospice and Palliative Medicine.
Sean Bain, MD, has been selected to the Glen Falls (N.Y.) Hospital Foundation Board of Trustees for 2018. Dr. Bain works as a hospitalist/internist at Glen Falls Hospital, where he is the president of medical staff. He manages the credentialing, continuing education, and policies and practices for the staff’s providers.
Dr. Bain received his medical degree at Albany (N.Y.) Medical College and served his residency at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
George Harrison, MD, has been tabbed the new chief medical officer at Fairview Park Hospital in Dublin, Ga. Dr. Harrison will be charged with managing clinical quality and patient safety, staff relations, and clinical integration strategies at the hospital.
Prior to his appointment, Dr. Harrison was the codirector of the hospitalist program at Fairview Park. The Georgia native previously worked in management roles at urgent care centers, family practice centers, and hospitalist programs in North Carolina, South Carolina, and Georgia. He is a member of the American Academy of Family Physicians, the Society of Hospital Medicine, and the American Academy of Physician Leaders.
Dr. Harrison taught high school geometry and chemistry before earning his medical degree at the Morehouse School of Medicine, Atlanta. He did his residency at Duke University Medical Center, Durham, N.C.
BUSINESS MOVES
U.S. Acute Care Solutions (Canton, Ohio), a physician-owned, national provider of emergency medicine and hospitalist services, has extended its relationship with Central Health of Colorado and western Kansas. USACS has acquired the physicians of Front Range Emergency Specialists (Colorado Springs, Colo.), Southwest Emergency Physicians (Durango, Colo.), and Southern Colorado Emergency Specialists (Pueblo, Colo.).
USACS’s acquisition of these three physician groups adds care to more than 175,000 patients each year in central and southwest Colorado. USACS cares for more than 6 million patients per year at more than 200 locations across the United States.
VEP Healthcare (Concord, Calif.), an emergency medicine and hospitalist staffing company, has signed on to manage hospitalist and ED services at City Hospital at White Rock in Dallas. Its goals are to increase patient satisfaction, decrease wait times in seeing providers, raise recommendation rates, and lower malpractice claims.
White Rock is a 218-bed, community hospital providing care to East Texas since 1959.
Modern Healthcare recently announced its list of the 50 Most Influential Physician Executives and Leaders, and hospital medicine was well represented among the honorees. The honored physicians were selected by a panel of experts and peers for their leadership and impact on the profession.
Topping the list was Scott Gottlieb, MD, the commissioner of the Food and Drug Administration. Dr. Gottlieb was confirmed to his position in May 2017 and, in his first year, has focused on price transparency and the approval of generic medications.
Dr. Gottlieb was deputy commissioner of the FDA from 2005-2007, and he has worked as an advisor and analyst for GlaxoSmithKline, the American Enterprise Institute, Vertex Pharmaceuticals, and Avilene Health.
Dr. Gottlieb earned his medical degree from the Icahn School of Medicine at Mount Sinai, New York, and completed his residency at Mount Sinai Hospital. He has worked as a hospitalist at New York University’s Tisch Hospital, the Hospital for Joint Diseases, and Stamford (Conn.) Hospital.
Patrick Conway, MD, was listed at number 23 on Modern Healthcare’s 50 Most Influential Physician Executives and Leaders. Formerly the deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services, Dr. Conway recently became president and chief executive officer of Blue Cross and Blue Shield of North Carolina.
Dr. Conway is known for his ability to develop and promote alternative payment models. He was elected to the National Academy of Medicine’s Institute of Medicine in 2014 and was selected as a Master of Hospital Medicine by the Society of Hospital Medicine.
Lynn Massingale, MD, the cofounder and chairman of TeamHealth, was named one of the 50 Most Influential Physician Executives and Leaders for a third year running, coming in at number 27 on the list. Dr. Massingale, who also recently was named to the Tennessee Healthcare Hall of Fame, founded TeamHealth in 1979 and was its chief executive officer for 30 years before assuming the role of chairman in 2008.
TeamHealth provides outsourced emergency medicine, hospitalist, critical care, anesthesiology, and acute care surgery services, among other specialties, at more than 3,200 facilities and physician groups across the United States.
Veeravat Taecharvongphairoj, MD, a veteran internist and hospitalist at Hemet Valley Medical Center in Hemet, Calif., has been honored by the International Association of Healthcare Professionals in its Leading Physicians of the World publication.
Dr. Taecharvongphairoj completed his residency at the University of Hawaii, Honolulu, before accepting a fellowship in hospital and palliative care at Cedars-Sinai Medical Center, Los Angeles. He is a member of the American Academy of Hospice and Palliative Medicine.
Sean Bain, MD, has been selected to the Glen Falls (N.Y.) Hospital Foundation Board of Trustees for 2018. Dr. Bain works as a hospitalist/internist at Glen Falls Hospital, where he is the president of medical staff. He manages the credentialing, continuing education, and policies and practices for the staff’s providers.
Dr. Bain received his medical degree at Albany (N.Y.) Medical College and served his residency at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
George Harrison, MD, has been tabbed the new chief medical officer at Fairview Park Hospital in Dublin, Ga. Dr. Harrison will be charged with managing clinical quality and patient safety, staff relations, and clinical integration strategies at the hospital.
Prior to his appointment, Dr. Harrison was the codirector of the hospitalist program at Fairview Park. The Georgia native previously worked in management roles at urgent care centers, family practice centers, and hospitalist programs in North Carolina, South Carolina, and Georgia. He is a member of the American Academy of Family Physicians, the Society of Hospital Medicine, and the American Academy of Physician Leaders.
Dr. Harrison taught high school geometry and chemistry before earning his medical degree at the Morehouse School of Medicine, Atlanta. He did his residency at Duke University Medical Center, Durham, N.C.
BUSINESS MOVES
U.S. Acute Care Solutions (Canton, Ohio), a physician-owned, national provider of emergency medicine and hospitalist services, has extended its relationship with Central Health of Colorado and western Kansas. USACS has acquired the physicians of Front Range Emergency Specialists (Colorado Springs, Colo.), Southwest Emergency Physicians (Durango, Colo.), and Southern Colorado Emergency Specialists (Pueblo, Colo.).
USACS’s acquisition of these three physician groups adds care to more than 175,000 patients each year in central and southwest Colorado. USACS cares for more than 6 million patients per year at more than 200 locations across the United States.
VEP Healthcare (Concord, Calif.), an emergency medicine and hospitalist staffing company, has signed on to manage hospitalist and ED services at City Hospital at White Rock in Dallas. Its goals are to increase patient satisfaction, decrease wait times in seeing providers, raise recommendation rates, and lower malpractice claims.
White Rock is a 218-bed, community hospital providing care to East Texas since 1959.
Modern Healthcare recently announced its list of the 50 Most Influential Physician Executives and Leaders, and hospital medicine was well represented among the honorees. The honored physicians were selected by a panel of experts and peers for their leadership and impact on the profession.
Topping the list was Scott Gottlieb, MD, the commissioner of the Food and Drug Administration. Dr. Gottlieb was confirmed to his position in May 2017 and, in his first year, has focused on price transparency and the approval of generic medications.
Dr. Gottlieb was deputy commissioner of the FDA from 2005-2007, and he has worked as an advisor and analyst for GlaxoSmithKline, the American Enterprise Institute, Vertex Pharmaceuticals, and Avilene Health.
Dr. Gottlieb earned his medical degree from the Icahn School of Medicine at Mount Sinai, New York, and completed his residency at Mount Sinai Hospital. He has worked as a hospitalist at New York University’s Tisch Hospital, the Hospital for Joint Diseases, and Stamford (Conn.) Hospital.
Patrick Conway, MD, was listed at number 23 on Modern Healthcare’s 50 Most Influential Physician Executives and Leaders. Formerly the deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services, Dr. Conway recently became president and chief executive officer of Blue Cross and Blue Shield of North Carolina.
Dr. Conway is known for his ability to develop and promote alternative payment models. He was elected to the National Academy of Medicine’s Institute of Medicine in 2014 and was selected as a Master of Hospital Medicine by the Society of Hospital Medicine.
Lynn Massingale, MD, the cofounder and chairman of TeamHealth, was named one of the 50 Most Influential Physician Executives and Leaders for a third year running, coming in at number 27 on the list. Dr. Massingale, who also recently was named to the Tennessee Healthcare Hall of Fame, founded TeamHealth in 1979 and was its chief executive officer for 30 years before assuming the role of chairman in 2008.
TeamHealth provides outsourced emergency medicine, hospitalist, critical care, anesthesiology, and acute care surgery services, among other specialties, at more than 3,200 facilities and physician groups across the United States.
Veeravat Taecharvongphairoj, MD, a veteran internist and hospitalist at Hemet Valley Medical Center in Hemet, Calif., has been honored by the International Association of Healthcare Professionals in its Leading Physicians of the World publication.
Dr. Taecharvongphairoj completed his residency at the University of Hawaii, Honolulu, before accepting a fellowship in hospital and palliative care at Cedars-Sinai Medical Center, Los Angeles. He is a member of the American Academy of Hospice and Palliative Medicine.
Sean Bain, MD, has been selected to the Glen Falls (N.Y.) Hospital Foundation Board of Trustees for 2018. Dr. Bain works as a hospitalist/internist at Glen Falls Hospital, where he is the president of medical staff. He manages the credentialing, continuing education, and policies and practices for the staff’s providers.
Dr. Bain received his medical degree at Albany (N.Y.) Medical College and served his residency at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
George Harrison, MD, has been tabbed the new chief medical officer at Fairview Park Hospital in Dublin, Ga. Dr. Harrison will be charged with managing clinical quality and patient safety, staff relations, and clinical integration strategies at the hospital.
Prior to his appointment, Dr. Harrison was the codirector of the hospitalist program at Fairview Park. The Georgia native previously worked in management roles at urgent care centers, family practice centers, and hospitalist programs in North Carolina, South Carolina, and Georgia. He is a member of the American Academy of Family Physicians, the Society of Hospital Medicine, and the American Academy of Physician Leaders.
Dr. Harrison taught high school geometry and chemistry before earning his medical degree at the Morehouse School of Medicine, Atlanta. He did his residency at Duke University Medical Center, Durham, N.C.
BUSINESS MOVES
U.S. Acute Care Solutions (Canton, Ohio), a physician-owned, national provider of emergency medicine and hospitalist services, has extended its relationship with Central Health of Colorado and western Kansas. USACS has acquired the physicians of Front Range Emergency Specialists (Colorado Springs, Colo.), Southwest Emergency Physicians (Durango, Colo.), and Southern Colorado Emergency Specialists (Pueblo, Colo.).
USACS’s acquisition of these three physician groups adds care to more than 175,000 patients each year in central and southwest Colorado. USACS cares for more than 6 million patients per year at more than 200 locations across the United States.
VEP Healthcare (Concord, Calif.), an emergency medicine and hospitalist staffing company, has signed on to manage hospitalist and ED services at City Hospital at White Rock in Dallas. Its goals are to increase patient satisfaction, decrease wait times in seeing providers, raise recommendation rates, and lower malpractice claims.
White Rock is a 218-bed, community hospital providing care to East Texas since 1959.
FDA attacks antibiotic resistance with new strategy
WASHINGTON – A strategy combining stewardship and science is needed to help combat antimicrobial resistance, and updated plans from the U.S. Food and Drug Administration include four key components to address all aspects of product development and use, FDA commissioner Scott Gottlieb, MD, said in a press briefing in Washington on Sept. 14.
“The FDA plays a unique role in advancing human and animal health” that provides a unique vantage point for coordinating all aspects of product development and application, he said.
The FDA’s comprehensive approach to the challenge of antimicrobial resistance (AMR) includes:
- Facilitating product development.
- Promoting antimicrobial stewardship.
- Supporting the development of new tools for surveillance.
- Advancing scientific initiatives, including research for the development of alternative treatments.
The FDA’s product development plan to combat AMR includes the creation of incentives for companies to develop new antibiotic products and create a robust pipeline, which is a challenge because of the lack of immediate economic gain, Dr. Gottlieb said.
“It necessary to change the perception that the costs and risks of antibiotic innovation are too high relative to their expected gains,” he emphasized.
Strategies to incentivize companies include fast track designation, priority review, and breakthrough therapy designation. In addition, the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD) is designed to promote development of antimicrobial drugs for limited and underserved populations, Dr. Gottlieb said. The FDA plan also calls for pursuing reimbursement options with the Centers for Medicare & Medicaid Services.
Promoting antimicrobial stewardship remains an ongoing element of the FDA’s plan to reduce AMR. In conjunction with the release of the FDA’s updated approach to AMR, the FDA’s Center for Veterinary Medicine CVM released a 5-year action plan to promote and support antimicrobial stewardship in not only the agricultural arena, but in companion animals as well.
The FDA plans to bring all antimicrobials of medical importance that are approved for use in animals under the oversight of CVM, which will pursue the improve labeling on antimicrobial drugs used in the feed and water of food-producing animals, including defining durations of use, Dr. Gottlieb noted.
Supporting the development and improvement of surveillance tools is “essential to understanding the drivers of resistance in human and veterinary settings and formulating appropriate responses” to outbreaks, Dr. Gottlieb said.
To help meet this goal, the FDA will expand sampling via the National Antimicrobial Resistance Monitoring System (NARMS) database, he said. Other surveillance goals include supporting genomics research and expanding AMR monitoring to include pathogens associated with animal feed and companion animals, he added.
As part of the final component of the FDA’s AMR strategy to advance scientific initiatives, the FDA has released a new Request for Information “to obtain additional, external input on how best to develop an annual list of regulatory science initiatives specific for antimicrobial products,” Dr. Gottlieb announced. The FDA intends to use the information gained from clinicians and others in its creation of guidance documents and recommendations to streamline the antibiotic development process. He also cited the FDA’s ongoing support of partnerships with public and private organizations such as the Clinical Trials Transformation Initiative, which focuses on drug development for severe bacterial infections with current unmet medical need.
“We need to harness science and policy to help our public health systems and researchers become nimbler in the battle against drug-resistant pathogens,” Dr. Gottlieb concluded.
In a panel discussion following the briefing, several experts offered perspective on the FDA’s goals and on the challenges of AMR.
William Flynn, DVM, deputy director of science policy for the Center of Veterinary Medicine, noted some goals for reducing the use of antibiotics in the veterinary arena.
“We are trying to focus on the driver: What are the disease conditions that drive use of the product,” he said. Ideally, better management of disease conditions can reduce reliance on antibiotics, he added.
Also in the panel discussion, Steven Gitterman, MD, deputy director of the division of microbiology devices at the Center for Devices and Radiological Health, emphasized the value of sustainable trial databases so AMR research can continue on an ongoing basis. Finally, Carolyn Wilson, PhD, associate director of research at the Center for Biologics Evaluation and Research, noted that the FDA’s research and development efforts include antibiotic alternatives, including live biotherapeutic products, fecal microbiota transplantation, and bacteriophage therapy.
Visit www.fda.gov for a transcript of Dr. Gottlieb’s talk, and for the updated FDA website page with more details on the agency’s plans to combat antimicrobial resistance.
Dr. Gottlieb and the panelists had no financial conflicts to disclose.
WASHINGTON – A strategy combining stewardship and science is needed to help combat antimicrobial resistance, and updated plans from the U.S. Food and Drug Administration include four key components to address all aspects of product development and use, FDA commissioner Scott Gottlieb, MD, said in a press briefing in Washington on Sept. 14.
“The FDA plays a unique role in advancing human and animal health” that provides a unique vantage point for coordinating all aspects of product development and application, he said.
The FDA’s comprehensive approach to the challenge of antimicrobial resistance (AMR) includes:
- Facilitating product development.
- Promoting antimicrobial stewardship.
- Supporting the development of new tools for surveillance.
- Advancing scientific initiatives, including research for the development of alternative treatments.
The FDA’s product development plan to combat AMR includes the creation of incentives for companies to develop new antibiotic products and create a robust pipeline, which is a challenge because of the lack of immediate economic gain, Dr. Gottlieb said.
“It necessary to change the perception that the costs and risks of antibiotic innovation are too high relative to their expected gains,” he emphasized.
Strategies to incentivize companies include fast track designation, priority review, and breakthrough therapy designation. In addition, the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD) is designed to promote development of antimicrobial drugs for limited and underserved populations, Dr. Gottlieb said. The FDA plan also calls for pursuing reimbursement options with the Centers for Medicare & Medicaid Services.
Promoting antimicrobial stewardship remains an ongoing element of the FDA’s plan to reduce AMR. In conjunction with the release of the FDA’s updated approach to AMR, the FDA’s Center for Veterinary Medicine CVM released a 5-year action plan to promote and support antimicrobial stewardship in not only the agricultural arena, but in companion animals as well.
The FDA plans to bring all antimicrobials of medical importance that are approved for use in animals under the oversight of CVM, which will pursue the improve labeling on antimicrobial drugs used in the feed and water of food-producing animals, including defining durations of use, Dr. Gottlieb noted.
Supporting the development and improvement of surveillance tools is “essential to understanding the drivers of resistance in human and veterinary settings and formulating appropriate responses” to outbreaks, Dr. Gottlieb said.
To help meet this goal, the FDA will expand sampling via the National Antimicrobial Resistance Monitoring System (NARMS) database, he said. Other surveillance goals include supporting genomics research and expanding AMR monitoring to include pathogens associated with animal feed and companion animals, he added.
As part of the final component of the FDA’s AMR strategy to advance scientific initiatives, the FDA has released a new Request for Information “to obtain additional, external input on how best to develop an annual list of regulatory science initiatives specific for antimicrobial products,” Dr. Gottlieb announced. The FDA intends to use the information gained from clinicians and others in its creation of guidance documents and recommendations to streamline the antibiotic development process. He also cited the FDA’s ongoing support of partnerships with public and private organizations such as the Clinical Trials Transformation Initiative, which focuses on drug development for severe bacterial infections with current unmet medical need.
“We need to harness science and policy to help our public health systems and researchers become nimbler in the battle against drug-resistant pathogens,” Dr. Gottlieb concluded.
In a panel discussion following the briefing, several experts offered perspective on the FDA’s goals and on the challenges of AMR.
William Flynn, DVM, deputy director of science policy for the Center of Veterinary Medicine, noted some goals for reducing the use of antibiotics in the veterinary arena.
“We are trying to focus on the driver: What are the disease conditions that drive use of the product,” he said. Ideally, better management of disease conditions can reduce reliance on antibiotics, he added.
Also in the panel discussion, Steven Gitterman, MD, deputy director of the division of microbiology devices at the Center for Devices and Radiological Health, emphasized the value of sustainable trial databases so AMR research can continue on an ongoing basis. Finally, Carolyn Wilson, PhD, associate director of research at the Center for Biologics Evaluation and Research, noted that the FDA’s research and development efforts include antibiotic alternatives, including live biotherapeutic products, fecal microbiota transplantation, and bacteriophage therapy.
Visit www.fda.gov for a transcript of Dr. Gottlieb’s talk, and for the updated FDA website page with more details on the agency’s plans to combat antimicrobial resistance.
Dr. Gottlieb and the panelists had no financial conflicts to disclose.
WASHINGTON – A strategy combining stewardship and science is needed to help combat antimicrobial resistance, and updated plans from the U.S. Food and Drug Administration include four key components to address all aspects of product development and use, FDA commissioner Scott Gottlieb, MD, said in a press briefing in Washington on Sept. 14.
“The FDA plays a unique role in advancing human and animal health” that provides a unique vantage point for coordinating all aspects of product development and application, he said.
The FDA’s comprehensive approach to the challenge of antimicrobial resistance (AMR) includes:
- Facilitating product development.
- Promoting antimicrobial stewardship.
- Supporting the development of new tools for surveillance.
- Advancing scientific initiatives, including research for the development of alternative treatments.
The FDA’s product development plan to combat AMR includes the creation of incentives for companies to develop new antibiotic products and create a robust pipeline, which is a challenge because of the lack of immediate economic gain, Dr. Gottlieb said.
“It necessary to change the perception that the costs and risks of antibiotic innovation are too high relative to their expected gains,” he emphasized.
Strategies to incentivize companies include fast track designation, priority review, and breakthrough therapy designation. In addition, the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD) is designed to promote development of antimicrobial drugs for limited and underserved populations, Dr. Gottlieb said. The FDA plan also calls for pursuing reimbursement options with the Centers for Medicare & Medicaid Services.
Promoting antimicrobial stewardship remains an ongoing element of the FDA’s plan to reduce AMR. In conjunction with the release of the FDA’s updated approach to AMR, the FDA’s Center for Veterinary Medicine CVM released a 5-year action plan to promote and support antimicrobial stewardship in not only the agricultural arena, but in companion animals as well.
The FDA plans to bring all antimicrobials of medical importance that are approved for use in animals under the oversight of CVM, which will pursue the improve labeling on antimicrobial drugs used in the feed and water of food-producing animals, including defining durations of use, Dr. Gottlieb noted.
Supporting the development and improvement of surveillance tools is “essential to understanding the drivers of resistance in human and veterinary settings and formulating appropriate responses” to outbreaks, Dr. Gottlieb said.
To help meet this goal, the FDA will expand sampling via the National Antimicrobial Resistance Monitoring System (NARMS) database, he said. Other surveillance goals include supporting genomics research and expanding AMR monitoring to include pathogens associated with animal feed and companion animals, he added.
As part of the final component of the FDA’s AMR strategy to advance scientific initiatives, the FDA has released a new Request for Information “to obtain additional, external input on how best to develop an annual list of regulatory science initiatives specific for antimicrobial products,” Dr. Gottlieb announced. The FDA intends to use the information gained from clinicians and others in its creation of guidance documents and recommendations to streamline the antibiotic development process. He also cited the FDA’s ongoing support of partnerships with public and private organizations such as the Clinical Trials Transformation Initiative, which focuses on drug development for severe bacterial infections with current unmet medical need.
“We need to harness science and policy to help our public health systems and researchers become nimbler in the battle against drug-resistant pathogens,” Dr. Gottlieb concluded.
In a panel discussion following the briefing, several experts offered perspective on the FDA’s goals and on the challenges of AMR.
William Flynn, DVM, deputy director of science policy for the Center of Veterinary Medicine, noted some goals for reducing the use of antibiotics in the veterinary arena.
“We are trying to focus on the driver: What are the disease conditions that drive use of the product,” he said. Ideally, better management of disease conditions can reduce reliance on antibiotics, he added.
Also in the panel discussion, Steven Gitterman, MD, deputy director of the division of microbiology devices at the Center for Devices and Radiological Health, emphasized the value of sustainable trial databases so AMR research can continue on an ongoing basis. Finally, Carolyn Wilson, PhD, associate director of research at the Center for Biologics Evaluation and Research, noted that the FDA’s research and development efforts include antibiotic alternatives, including live biotherapeutic products, fecal microbiota transplantation, and bacteriophage therapy.
Visit www.fda.gov for a transcript of Dr. Gottlieb’s talk, and for the updated FDA website page with more details on the agency’s plans to combat antimicrobial resistance.
Dr. Gottlieb and the panelists had no financial conflicts to disclose.
Hospitalist NPs and PAs note progress
But remain underutilized
Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.
One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.
At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.
Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.
Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.
But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.
The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.
“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
Goals, roles, and expectations
Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.
Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.
“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”
Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.
“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.
Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.
“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”
Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”
Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.
For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.
For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.
Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”
Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
Debunking myths
Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.
“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”
But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.
“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”
She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.
“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”
Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.
“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.
Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.
“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
Changing practice
Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.
“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.
As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.
But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.
“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”
Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.
“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”
PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.
“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”
Onboarding NPs and PAs
According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.
To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.
Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.
But remain underutilized
But remain underutilized
Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.
One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.
At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.
Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.
Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.
But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.
The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.
“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
Goals, roles, and expectations
Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.
Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.
“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”
Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.
“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.
Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.
“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”
Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”
Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.
For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.
For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.
Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”
Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
Debunking myths
Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.
“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”
But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.
“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”
She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.
“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”
Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.
“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.
Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.
“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
Changing practice
Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.
“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.
As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.
But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.
“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”
Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.
“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”
PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.
“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”
Onboarding NPs and PAs
According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.
To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.
Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.
Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.
One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.
At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.
Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.
Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.
But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.
The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.
“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
Goals, roles, and expectations
Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.
Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.
“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”
Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.
“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.
Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.
“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”
Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”
Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.
For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.
For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.
Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”
Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
Debunking myths
Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.
“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”
But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.
“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”
She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.
“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”
Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.
“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.
Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.
“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
Changing practice
Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.
“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.
As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.
But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.
“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”
Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.
“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”
PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.
“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”
Onboarding NPs and PAs
According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.
To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.
Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.
EXPERT ANALYSIS FROM HM18