Managing Your Practice

Despite calls for board-certified intensivists to manage all critically ill patients, only a third of hospitalized ICU patients currently are seen by such a specialist—mostly because there are not enough of them to go around.^1,2 More and more hospitalists, especially those in community hospitals, are working in ICUs (see “The Critical-Care Debate,”). With the proper training, that can be a good thing for patients and hospitalists, according to a Research, Innovations, and Clinical Vignettes (RIV) abstract presented at HM12 in San Diego.³

Lead author and hospitalist Mark Krivopal, MD, SFHM, formerly with TeamHealth in California and now vice president and medical director of clinical integration and hospital medicine at Steward Health Care in Boston, outlined a program at California’s Lodi Memorial Hospital that identified a group of hospitalists who had experience in caring for critically ill patients and credentials to perform such procedures as central-line placements, intubations, and ventilator management. The select group of TeamHealth hospitalists completed a two-day “Fundamentals of Critical Care Support” course offered by the Society of Critical Care Medicine (www.sccm.org), then began covering the ICU in shifts from 7 a.m. to 7 p.m. The program was so successful early on that hospital administration requested that it expand to a 24-hour service.

An ICU hospitalist program needs to be a partnership, Dr. Krivopal says. Essential oversight at Lodi Memorial is provided by the hospital’s sole pulmonologist.

Preliminary data showed a 35% reduction in ventilator days and 22% reduction in ICU stays, Dr. Krivopal says. The hospital also reports high satisfaction from nurses and other staff. Additional metrics, such as cost savings and patient satisfaction, are under review.

“So long as the level of training is sufficient, this is an approach that definitely should be explored,” he says, adding that young internists have many of the skills needed for ICU work. “But if you don’t keep those skills up [with practice] after residency, you lose them.”

References

1. The Leapfrog Group. ICU physician staffing fact sheet. The Leapfrog Group website. Available at: http://www.leapfroggroup.org/media/file/Leapfrog-ICU_Physician_Staffing_Fact_Sheet.pdf. Accessed Aug. 29, 2012.
2. Health Resources & Services Administration. Report to Congress: The critical care workforce: a study of the supply and demand for critical care physicians. U.S. Department of Health & Human Services website. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed Aug. 29, 2012.
3. Krivopal M, Hlaing M, Felber R, Himebaugh R. ICU hospitalist: a novel method of care for the critically ill patients in economically lean times. J Hosp Med. 2012;7(Suppl 2):192.

Despite calls for board-certified intensivists to manage all critically ill patients, only a third of hospitalized ICU patients currently are seen by such a specialist—mostly because there are not enough of them to go around.^1,2 More and more hospitalists, especially those in community hospitals, are working in ICUs (see “The Critical-Care Debate,”). With the proper training, that can be a good thing for patients and hospitalists, according to a Research, Innovations, and Clinical Vignettes (RIV) abstract presented at HM12 in San Diego.³

Lead author and hospitalist Mark Krivopal, MD, SFHM, formerly with TeamHealth in California and now vice president and medical director of clinical integration and hospital medicine at Steward Health Care in Boston, outlined a program at California’s Lodi Memorial Hospital that identified a group of hospitalists who had experience in caring for critically ill patients and credentials to perform such procedures as central-line placements, intubations, and ventilator management. The select group of TeamHealth hospitalists completed a two-day “Fundamentals of Critical Care Support” course offered by the Society of Critical Care Medicine (www.sccm.org), then began covering the ICU in shifts from 7 a.m. to 7 p.m. The program was so successful early on that hospital administration requested that it expand to a 24-hour service.

An ICU hospitalist program needs to be a partnership, Dr. Krivopal says. Essential oversight at Lodi Memorial is provided by the hospital’s sole pulmonologist.

Preliminary data showed a 35% reduction in ventilator days and 22% reduction in ICU stays, Dr. Krivopal says. The hospital also reports high satisfaction from nurses and other staff. Additional metrics, such as cost savings and patient satisfaction, are under review.

“So long as the level of training is sufficient, this is an approach that definitely should be explored,” he says, adding that young internists have many of the skills needed for ICU work. “But if you don’t keep those skills up [with practice] after residency, you lose them.”

References

1. The Leapfrog Group. ICU physician staffing fact sheet. The Leapfrog Group website. Available at: http://www.leapfroggroup.org/media/file/Leapfrog-ICU_Physician_Staffing_Fact_Sheet.pdf. Accessed Aug. 29, 2012.
2. Health Resources & Services Administration. Report to Congress: The critical care workforce: a study of the supply and demand for critical care physicians. U.S. Department of Health & Human Services website. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed Aug. 29, 2012.
3. Krivopal M, Hlaing M, Felber R, Himebaugh R. ICU hospitalist: a novel method of care for the critically ill patients in economically lean times. J Hosp Med. 2012;7(Suppl 2):192.

Despite calls for board-certified intensivists to manage all critically ill patients, only a third of hospitalized ICU patients currently are seen by such a specialist—mostly because there are not enough of them to go around.^1,2 More and more hospitalists, especially those in community hospitals, are working in ICUs (see “The Critical-Care Debate,”). With the proper training, that can be a good thing for patients and hospitalists, according to a Research, Innovations, and Clinical Vignettes (RIV) abstract presented at HM12 in San Diego.³

Lead author and hospitalist Mark Krivopal, MD, SFHM, formerly with TeamHealth in California and now vice president and medical director of clinical integration and hospital medicine at Steward Health Care in Boston, outlined a program at California’s Lodi Memorial Hospital that identified a group of hospitalists who had experience in caring for critically ill patients and credentials to perform such procedures as central-line placements, intubations, and ventilator management. The select group of TeamHealth hospitalists completed a two-day “Fundamentals of Critical Care Support” course offered by the Society of Critical Care Medicine (www.sccm.org), then began covering the ICU in shifts from 7 a.m. to 7 p.m. The program was so successful early on that hospital administration requested that it expand to a 24-hour service.

An ICU hospitalist program needs to be a partnership, Dr. Krivopal says. Essential oversight at Lodi Memorial is provided by the hospital’s sole pulmonologist.

Preliminary data showed a 35% reduction in ventilator days and 22% reduction in ICU stays, Dr. Krivopal says. The hospital also reports high satisfaction from nurses and other staff. Additional metrics, such as cost savings and patient satisfaction, are under review.

“So long as the level of training is sufficient, this is an approach that definitely should be explored,” he says, adding that young internists have many of the skills needed for ICU work. “But if you don’t keep those skills up [with practice] after residency, you lose them.”

References

1. The Leapfrog Group. ICU physician staffing fact sheet. The Leapfrog Group website. Available at: http://www.leapfroggroup.org/media/file/Leapfrog-ICU_Physician_Staffing_Fact_Sheet.pdf. Accessed Aug. 29, 2012.
2. Health Resources & Services Administration. Report to Congress: The critical care workforce: a study of the supply and demand for critical care physicians. U.S. Department of Health & Human Services website. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed Aug. 29, 2012.
3. Krivopal M, Hlaing M, Felber R, Himebaugh R. ICU hospitalist: a novel method of care for the critically ill patients in economically lean times. J Hosp Med. 2012;7(Suppl 2):192.

A new study tracking the growth of advanced diagnostic imaging techniques found that the rate of growth for such tests is slowing dramatically, even as the total number of tests performed continues to grow.¹ Starting in 2007, the rate of growth dropped sharply to about 1% to 3% from more than 6% per year during the previous decade.

Frank Levy, PhD, professor of urban economics at Massachusetts Institute of Technology in Cambridge, Mass., and one of the study’s authors, suggests that the previous growth of the technology could have been partly attributable to such nonmedical factors as profitability for hospitals and fear of malpractice by physicians. The slowdown, Dr. Levy says, also might reflect increased pushback from insurers, recognition of the cost and waste issues, and growing concerns about radiation exposure.

“There are many medical reasons for using these procedures—and many nonmedical reasons,” Dr. Levy says. “To use healthcare resources more efficiently, you should make sure your reason for ordering these tests is medical.”

SHM is working on a short list of sometimes unnecessary but commonly performed medical procedures, which it plans to submit to the American Board of Internal Medicine’s Choosing Wisely campaign this fall. One of the tests being considered for this list is serial chest X-rays for hospitalized patients outside of the ICU who are clinically stable, says Wendy Nickel, associate vice president of SHM’s Center for Hospital Innovation and Improvement. Unnecessary imaging tests are both a safety and a waste issue, she adds.

In related news, a study in the Journal of the National Cancer Institute found that 95.9% of patients 65 and older who have Stage IV cancer received at least one high-cost advanced imaging procedure (e.g. PET or nuclear medicine), with their utilization rates rising more rapidly than for earlier stages of disease.² Such tests can lead to appropriate palliative measures but also can “distract patients from focusing on achievable end-of-life goals,” explain researchers from the Dana-Farber Cancer Institute in Boston.

References

1. Lee D, Levy F. The sharp slowdown in growth of medical imaging: an early analysis suggests combination of policies was the cause. Health Affairs website. Available at: http://www.healthaffairs.org/alert_link.php?url=http://content.healthaffairs.org/content/early/2012/07/24/hlthaff.2011.1034&t=h&id=1590. Accessed Aug. 29, 2012.
2. Hu YY, Kwok AC, Jiang W, et al. High-cost imaging in elderly patients with Stage IV cancer. J Natl Cancer Inst. 2012;104(15):1165-1173.

A new study tracking the growth of advanced diagnostic imaging techniques found that the rate of growth for such tests is slowing dramatically, even as the total number of tests performed continues to grow.¹ Starting in 2007, the rate of growth dropped sharply to about 1% to 3% from more than 6% per year during the previous decade.

Frank Levy, PhD, professor of urban economics at Massachusetts Institute of Technology in Cambridge, Mass., and one of the study’s authors, suggests that the previous growth of the technology could have been partly attributable to such nonmedical factors as profitability for hospitals and fear of malpractice by physicians. The slowdown, Dr. Levy says, also might reflect increased pushback from insurers, recognition of the cost and waste issues, and growing concerns about radiation exposure.

“There are many medical reasons for using these procedures—and many nonmedical reasons,” Dr. Levy says. “To use healthcare resources more efficiently, you should make sure your reason for ordering these tests is medical.”

SHM is working on a short list of sometimes unnecessary but commonly performed medical procedures, which it plans to submit to the American Board of Internal Medicine’s Choosing Wisely campaign this fall. One of the tests being considered for this list is serial chest X-rays for hospitalized patients outside of the ICU who are clinically stable, says Wendy Nickel, associate vice president of SHM’s Center for Hospital Innovation and Improvement. Unnecessary imaging tests are both a safety and a waste issue, she adds.

In related news, a study in the Journal of the National Cancer Institute found that 95.9% of patients 65 and older who have Stage IV cancer received at least one high-cost advanced imaging procedure (e.g. PET or nuclear medicine), with their utilization rates rising more rapidly than for earlier stages of disease.² Such tests can lead to appropriate palliative measures but also can “distract patients from focusing on achievable end-of-life goals,” explain researchers from the Dana-Farber Cancer Institute in Boston.

References

1. Lee D, Levy F. The sharp slowdown in growth of medical imaging: an early analysis suggests combination of policies was the cause. Health Affairs website. Available at: http://www.healthaffairs.org/alert_link.php?url=http://content.healthaffairs.org/content/early/2012/07/24/hlthaff.2011.1034&t=h&id=1590. Accessed Aug. 29, 2012.
2. Hu YY, Kwok AC, Jiang W, et al. High-cost imaging in elderly patients with Stage IV cancer. J Natl Cancer Inst. 2012;104(15):1165-1173.

A new study tracking the growth of advanced diagnostic imaging techniques found that the rate of growth for such tests is slowing dramatically, even as the total number of tests performed continues to grow.¹ Starting in 2007, the rate of growth dropped sharply to about 1% to 3% from more than 6% per year during the previous decade.

Frank Levy, PhD, professor of urban economics at Massachusetts Institute of Technology in Cambridge, Mass., and one of the study’s authors, suggests that the previous growth of the technology could have been partly attributable to such nonmedical factors as profitability for hospitals and fear of malpractice by physicians. The slowdown, Dr. Levy says, also might reflect increased pushback from insurers, recognition of the cost and waste issues, and growing concerns about radiation exposure.

“There are many medical reasons for using these procedures—and many nonmedical reasons,” Dr. Levy says. “To use healthcare resources more efficiently, you should make sure your reason for ordering these tests is medical.”

SHM is working on a short list of sometimes unnecessary but commonly performed medical procedures, which it plans to submit to the American Board of Internal Medicine’s Choosing Wisely campaign this fall. One of the tests being considered for this list is serial chest X-rays for hospitalized patients outside of the ICU who are clinically stable, says Wendy Nickel, associate vice president of SHM’s Center for Hospital Innovation and Improvement. Unnecessary imaging tests are both a safety and a waste issue, she adds.

In related news, a study in the Journal of the National Cancer Institute found that 95.9% of patients 65 and older who have Stage IV cancer received at least one high-cost advanced imaging procedure (e.g. PET or nuclear medicine), with their utilization rates rising more rapidly than for earlier stages of disease.² Such tests can lead to appropriate palliative measures but also can “distract patients from focusing on achievable end-of-life goals,” explain researchers from the Dana-Farber Cancer Institute in Boston.

References

1. Lee D, Levy F. The sharp slowdown in growth of medical imaging: an early analysis suggests combination of policies was the cause. Health Affairs website. Available at: http://www.healthaffairs.org/alert_link.php?url=http://content.healthaffairs.org/content/early/2012/07/24/hlthaff.2011.1034&t=h&id=1590. Accessed Aug. 29, 2012.
2. Hu YY, Kwok AC, Jiang W, et al. High-cost imaging in elderly patients with Stage IV cancer. J Natl Cancer Inst. 2012;104(15):1165-1173.

Sleep-disturbing noise in the hospital is a big problem “that can really compromise a patient’s recovery process,” according to Orfeu Buxton, PhD, associate neuroscientist in the Division of Sleep Medicine at Brigham & Women’s Hospital in Boston.¹

Researchers exposed a dozen healthy volunteers to typical nocturnal hospital noise while monitoring their sleep patterns and heart rates, systematically quantifying the disruptive capacity of a range of hospital sounds on sleep. Hospitalized patients routinely cite noise as a major factor that negatively affects quality of care, the researchers note. An Aug. 2 New York Times blog post by Pauline Chen, MD, suggests that government policies linking hospital reimbursement to patient satisfaction might finally turn hospital administrators’ focus on the need to bring this noise under better control.²

References

1. Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med. 2012;157(3):170-179.
2. Chen P. The clatter of the hospital room. New York Times website. Available at: http://well.blogs.nytimes.com/2012/08/02/the-clatter-of-the-hospital-room/. Accessed Aug. 29, 2012.

Sleep-disturbing noise in the hospital is a big problem “that can really compromise a patient’s recovery process,” according to Orfeu Buxton, PhD, associate neuroscientist in the Division of Sleep Medicine at Brigham & Women’s Hospital in Boston.¹

Researchers exposed a dozen healthy volunteers to typical nocturnal hospital noise while monitoring their sleep patterns and heart rates, systematically quantifying the disruptive capacity of a range of hospital sounds on sleep. Hospitalized patients routinely cite noise as a major factor that negatively affects quality of care, the researchers note. An Aug. 2 New York Times blog post by Pauline Chen, MD, suggests that government policies linking hospital reimbursement to patient satisfaction might finally turn hospital administrators’ focus on the need to bring this noise under better control.²

References

1. Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med. 2012;157(3):170-179.
2. Chen P. The clatter of the hospital room. New York Times website. Available at: http://well.blogs.nytimes.com/2012/08/02/the-clatter-of-the-hospital-room/. Accessed Aug. 29, 2012.

Sleep-disturbing noise in the hospital is a big problem “that can really compromise a patient’s recovery process,” according to Orfeu Buxton, PhD, associate neuroscientist in the Division of Sleep Medicine at Brigham & Women’s Hospital in Boston.¹

Researchers exposed a dozen healthy volunteers to typical nocturnal hospital noise while monitoring their sleep patterns and heart rates, systematically quantifying the disruptive capacity of a range of hospital sounds on sleep. Hospitalized patients routinely cite noise as a major factor that negatively affects quality of care, the researchers note. An Aug. 2 New York Times blog post by Pauline Chen, MD, suggests that government policies linking hospital reimbursement to patient satisfaction might finally turn hospital administrators’ focus on the need to bring this noise under better control.²

References

1. Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med. 2012;157(3):170-179.
2. Chen P. The clatter of the hospital room. New York Times website. Available at: http://well.blogs.nytimes.com/2012/08/02/the-clatter-of-the-hospital-room/. Accessed Aug. 29, 2012.

Only about a third of ideal candidates with heart failure are currently treated with [aldosterone antagonists], even though it markedly improves outcome and is Class I-recommended in the guidelines.

—Gregg Fonarow, MD, co-chief, University of California at Los Angeles division of cardiology, chair, American Heart Association’s Get With The Guidelines program steering committee

You might not have done a fellowship in cardiology, but quite often you probably feel like a cardiologist. Hospitalists frequently attend to patients on observation for heart problems and help manage even the most complex patients.

Often, you are working alongside the cardiologist. But other times, you’re on your own. Hospitalists are expected to carry an increasingly heavy load when it comes to heart-failure patients and many other kinds of patients with specialized disorders. It can be hard to keep up with what you need to know.

Top Twelve

1. Recognize the new importance of beta-blockers for heart failure, and go with the best of them.
2. It’s not readmissions that are the problem—it’s avoidable readmissions.
3. New interventional technologies will mean more complex patients, so be ready.
4. Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
5. Switching from IV diuretics to an oral regimen calls for careful monitoring.
6. Patients with heart failure with preserved ejection fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.
7. Inotropic agents can do more harm than good.
8. Pay attention to the ins and outs of new antiplatelet therapies.
9. Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.
10. Some non-STEMI patients might benefit from getting to the catheterization lab quickly.
11. Beware the idiosyncrasies of new anticoagulants.
12. Be cognizant of stent thrombosis and how to manage it.

The Hospitalist spoke to several cardiologists about the latest in treatments, technologies, and HM’s role in the system of care. The following are their suggestions for what you really need to know about treating patients with heart conditions.

1) Recognize the new importance of beta-blockers for heart failure, and go with the best of them.

Angiotensin converting enzyme inhibitors and angiotensive receptor blockers have been part of the Centers for Medicare & Medicaid Services’ (CMS) core measures for heart failure for a long time, but beta-blockers at hospital discharge only recently have been added as American College of Cardiology/American Heart Association/American Medical Association–Physician Consortium for Performance Improvement measures for heart failure.¹

“For those with heart failure and reduced left ventricular ejection fraction, very old and outdated concepts would have talked about potentially holding the beta-blocker during hospitalization for heart failure—or not initiating until the patient was an outpatient,” says Gregg Fonarow, MD, co-chief of the University of California at Los Angeles’ division of cardiology and chair of the steering committee for the American Heart Association’s Get With The Guidelines program. “[But] the guidelines and evidence, and often performance measures, linked to them are now explicit about initiating or maintaining beta-blockers during the heart-failure hospitalization.”

Beta-blockers should be initiated as patients are stabilized before discharge. Dr. Fonarow suggests hospitalists use only one of the three evidence-based therapies: carvedilol, metoprolol succinate, or bisoprolol.

“Many physicians have been using metoprolol tartrate or atenolol in heart-failure patients,” Dr. Fonarow says. “These are not known to improve clinical outcomes. So here’s an example where the specific medication is absolutely, critically important.”

2) It’s not readmissions that are the problem—it’s avoidable readmissions.

“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”

Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.² He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”

“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”

3) New interventional technologies will mean more complex patients, so be ready.

Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.

“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”

Many of these patients have other problems, including renal insufficiency, diabetes, and the like.

“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.

4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.

Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.

“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”

5) Switching from IV diuretics to an oral regimen calls for careful monitoring.

Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.

Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.

“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”

6) Patients with heart failure with preserved ejection

fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.

“We really can’t exercise a thought economy that just says, ‘Extrapolate the evidence-based therapies for heart failure with reduced ejection fraction to heart failure with preserved ejection fraction’ and expect good outcomes,” Dr. Yancy says. “That’s not the case. We don’t have an evidence base to substantiate that.”

He says one or more common comorbidities (e.g. atrial fibrillation, hypertension, obesity, diabetes, renal insufficiency) are present in 90% of patients with preserved ejection fraction. Treatment of those comorbidities—for example, rate control in afib patients, lowering the blood pressure in hypertension patients—has to be done with care.

“We should recognize that the therapy for this condition, albeit absent any specifically indicated interventions that will change its natural history, can still be skillfully constructed,” Dr. Yancy says. “But that construct needs to reflect the recommended, guideline-driven interventions for the concomitant other comorbidities.”

7) Inotropic agents can do more harm than good.

For patients who aren’t in cardiogenic shock, using inotropic agents doesn’t help. In fact, it might actually hurt. Dr. Fonarow says studies have shown these agents can “prolong length of stay, cause complications, and increase mortality risk.”

He notes that the use of inotropes should be avoided, or if it’s being considered, a cardiologist with knowledge and experience in heart failure should be involved in the treatment and care.

Statements about avoiding inotropes in heart failure, except under very specific circumstances, have been “incredibly strengthened” recently in the American College of Cardiology and Heart Failure Society of America guidelines.³

8) Pay attention to the ins and outs of new antiplatelet therapies.

For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event. There’s no simple antidote.

—John Harold, MD, president-elect, American College of Cardiology, former chief of staff, department of medicine, Cedars-Sinai Medical Center, Los Angeles

Hospitalists caring for acute coronary syndrome patients need to familiarize themselves with updated guidelines and additional therapies that are now available, Dr. Fonarow says. New antiplatelet therapies (e.g. prasugrel and ticagrelor) are available as part of the armamentarium, along with the mainstay clopidogrel.

“These therapies lower the risk of recurrent events, lowered the risk of stent thrombosis,” he says. “In the case of ticagrelor, it actually lowered all-cause mortality. These are important new therapies, with new guideline recommendations, that all hospitalists should be aware of.”

9) Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.

“Patients getting such devices as pacemakers or implantable cardioverter defribrillators (ICD) installed tend not to need bridging,” says Joaquin Cigarroa, MD, clinical chief of cardiology at Oregon Health & Science University in Portland.

He says it’s actually “safer” to do the procedure when patients “are on oral antithrombotics than switching them from an oral agent, and bridging with low- molecular-weight- or unfractionated heparin.”

“It’s a big deal,” Dr. Cigarroa adds, because it is risky to have elderly and frail patients on multiple antithrombotics. “Hemorrhagic complications in cardiology patients still occurs very frequently, so really be attuned to estimating bleeding risk and making sure that we’re dosing antithrombotics appropriately. Bridging should be the minority of patients, not the majority of patients.”

10) Some non-STEMI patients might benefit from getting to the catheterization lab quickly.

Door-to-balloon time is recognized as critical for ST-segment elevation myocardial infarction (STEMI) patients, but more recent work—such as in the TIMACS trial—finds benefits of early revascularization for some non-STEMI patients as well.²

“This trial showed that among higher-risk patients, using a validated risk score, that those patients did benefit from an early approach, meaning going to the cath lab in the first 12 hours of hospitalization,” Dr. Fonarow says. “We now have more information about the optimal timing of coronary angiography and potential revascularization of higher-risk patients with non-ST-segment elevation MI.”

11) Beware the idiosyncrasies of new anticoagulants.

The introduction of dabigatran and rivaroxaban (and, perhaps soon, apixaban) to the array of anticoagulant therapies brings a new slate of considerations for hospitalists, Dr. Harold says.

“For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event,” he says. “There’s no simple antidote. And the effect can last up to 12 to 24 hours, depending on the renal function. This is what the hospitalist will be called to deal with: bleeding complications in patients who have these newer anticoagulants on board.”

Dr. Fonarow says that the new CHA2DS2-VASc score has been found to do a better job than the traditional CHADS2 score in assessing afib stroke risk.⁴

12) Be cognizant of stent thrombosis and how to manage it.

Dr. Harold says that most hospitalists probably are up to date on drug-eluting stents and the risk of stopping dual antiplatelet therapy within several months of implant, but that doesn’t mean they won’t treat patients whose primary-care physicians (PCPs) aren’t up to date. He recommends working on these cases with hematologists.

“That knowledge is not widespread in terms of the internal-medicine community,” he says. “I’ve seen situations where patients have had their Plavix stopped for colonoscopies and they’ve had stent thrombosis. It’s this knowledge of cardiac patients who come in with recent deployment of drug-eluting stents who may end up having other issues.”

Tom Collins is a freelance writer in South Florida.

References

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119:1977-2016 an HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure. 2010;16(6):475-539.
2. Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297-298.
3. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.
4. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172-1179.
5. Associations between outpatient heart failure process-of-care measures and mortality. Circulation. 2011;123(15):1601-1610.

Only about a third of ideal candidates with heart failure are currently treated with [aldosterone antagonists], even though it markedly improves outcome and is Class I-recommended in the guidelines.

—Gregg Fonarow, MD, co-chief, University of California at Los Angeles division of cardiology, chair, American Heart Association’s Get With The Guidelines program steering committee

You might not have done a fellowship in cardiology, but quite often you probably feel like a cardiologist. Hospitalists frequently attend to patients on observation for heart problems and help manage even the most complex patients.

Often, you are working alongside the cardiologist. But other times, you’re on your own. Hospitalists are expected to carry an increasingly heavy load when it comes to heart-failure patients and many other kinds of patients with specialized disorders. It can be hard to keep up with what you need to know.

Top Twelve

1. Recognize the new importance of beta-blockers for heart failure, and go with the best of them.
2. It’s not readmissions that are the problem—it’s avoidable readmissions.
3. New interventional technologies will mean more complex patients, so be ready.
4. Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
5. Switching from IV diuretics to an oral regimen calls for careful monitoring.
6. Patients with heart failure with preserved ejection fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.
7. Inotropic agents can do more harm than good.
8. Pay attention to the ins and outs of new antiplatelet therapies.
9. Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.
10. Some non-STEMI patients might benefit from getting to the catheterization lab quickly.
11. Beware the idiosyncrasies of new anticoagulants.
12. Be cognizant of stent thrombosis and how to manage it.

The Hospitalist spoke to several cardiologists about the latest in treatments, technologies, and HM’s role in the system of care. The following are their suggestions for what you really need to know about treating patients with heart conditions.

1) Recognize the new importance of beta-blockers for heart failure, and go with the best of them.

Angiotensin converting enzyme inhibitors and angiotensive receptor blockers have been part of the Centers for Medicare & Medicaid Services’ (CMS) core measures for heart failure for a long time, but beta-blockers at hospital discharge only recently have been added as American College of Cardiology/American Heart Association/American Medical Association–Physician Consortium for Performance Improvement measures for heart failure.¹

“For those with heart failure and reduced left ventricular ejection fraction, very old and outdated concepts would have talked about potentially holding the beta-blocker during hospitalization for heart failure—or not initiating until the patient was an outpatient,” says Gregg Fonarow, MD, co-chief of the University of California at Los Angeles’ division of cardiology and chair of the steering committee for the American Heart Association’s Get With The Guidelines program. “[But] the guidelines and evidence, and often performance measures, linked to them are now explicit about initiating or maintaining beta-blockers during the heart-failure hospitalization.”

Beta-blockers should be initiated as patients are stabilized before discharge. Dr. Fonarow suggests hospitalists use only one of the three evidence-based therapies: carvedilol, metoprolol succinate, or bisoprolol.

“Many physicians have been using metoprolol tartrate or atenolol in heart-failure patients,” Dr. Fonarow says. “These are not known to improve clinical outcomes. So here’s an example where the specific medication is absolutely, critically important.”

2) It’s not readmissions that are the problem—it’s avoidable readmissions.

“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”

Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.² He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”

“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”

3) New interventional technologies will mean more complex patients, so be ready.

Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.

“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”

Many of these patients have other problems, including renal insufficiency, diabetes, and the like.

“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.

4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.

Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.

“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”

5) Switching from IV diuretics to an oral regimen calls for careful monitoring.

Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.

Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.

“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”

6) Patients with heart failure with preserved ejection

fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.

“We really can’t exercise a thought economy that just says, ‘Extrapolate the evidence-based therapies for heart failure with reduced ejection fraction to heart failure with preserved ejection fraction’ and expect good outcomes,” Dr. Yancy says. “That’s not the case. We don’t have an evidence base to substantiate that.”

He says one or more common comorbidities (e.g. atrial fibrillation, hypertension, obesity, diabetes, renal insufficiency) are present in 90% of patients with preserved ejection fraction. Treatment of those comorbidities—for example, rate control in afib patients, lowering the blood pressure in hypertension patients—has to be done with care.

“We should recognize that the therapy for this condition, albeit absent any specifically indicated interventions that will change its natural history, can still be skillfully constructed,” Dr. Yancy says. “But that construct needs to reflect the recommended, guideline-driven interventions for the concomitant other comorbidities.”

7) Inotropic agents can do more harm than good.

For patients who aren’t in cardiogenic shock, using inotropic agents doesn’t help. In fact, it might actually hurt. Dr. Fonarow says studies have shown these agents can “prolong length of stay, cause complications, and increase mortality risk.”

He notes that the use of inotropes should be avoided, or if it’s being considered, a cardiologist with knowledge and experience in heart failure should be involved in the treatment and care.

Statements about avoiding inotropes in heart failure, except under very specific circumstances, have been “incredibly strengthened” recently in the American College of Cardiology and Heart Failure Society of America guidelines.³

8) Pay attention to the ins and outs of new antiplatelet therapies.

For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event. There’s no simple antidote.

—John Harold, MD, president-elect, American College of Cardiology, former chief of staff, department of medicine, Cedars-Sinai Medical Center, Los Angeles

Hospitalists caring for acute coronary syndrome patients need to familiarize themselves with updated guidelines and additional therapies that are now available, Dr. Fonarow says. New antiplatelet therapies (e.g. prasugrel and ticagrelor) are available as part of the armamentarium, along with the mainstay clopidogrel.

“These therapies lower the risk of recurrent events, lowered the risk of stent thrombosis,” he says. “In the case of ticagrelor, it actually lowered all-cause mortality. These are important new therapies, with new guideline recommendations, that all hospitalists should be aware of.”

9) Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.

“Patients getting such devices as pacemakers or implantable cardioverter defribrillators (ICD) installed tend not to need bridging,” says Joaquin Cigarroa, MD, clinical chief of cardiology at Oregon Health & Science University in Portland.

He says it’s actually “safer” to do the procedure when patients “are on oral antithrombotics than switching them from an oral agent, and bridging with low- molecular-weight- or unfractionated heparin.”

“It’s a big deal,” Dr. Cigarroa adds, because it is risky to have elderly and frail patients on multiple antithrombotics. “Hemorrhagic complications in cardiology patients still occurs very frequently, so really be attuned to estimating bleeding risk and making sure that we’re dosing antithrombotics appropriately. Bridging should be the minority of patients, not the majority of patients.”

10) Some non-STEMI patients might benefit from getting to the catheterization lab quickly.

Door-to-balloon time is recognized as critical for ST-segment elevation myocardial infarction (STEMI) patients, but more recent work—such as in the TIMACS trial—finds benefits of early revascularization for some non-STEMI patients as well.²

“This trial showed that among higher-risk patients, using a validated risk score, that those patients did benefit from an early approach, meaning going to the cath lab in the first 12 hours of hospitalization,” Dr. Fonarow says. “We now have more information about the optimal timing of coronary angiography and potential revascularization of higher-risk patients with non-ST-segment elevation MI.”

11) Beware the idiosyncrasies of new anticoagulants.

The introduction of dabigatran and rivaroxaban (and, perhaps soon, apixaban) to the array of anticoagulant therapies brings a new slate of considerations for hospitalists, Dr. Harold says.

“For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event,” he says. “There’s no simple antidote. And the effect can last up to 12 to 24 hours, depending on the renal function. This is what the hospitalist will be called to deal with: bleeding complications in patients who have these newer anticoagulants on board.”

Dr. Fonarow says that the new CHA2DS2-VASc score has been found to do a better job than the traditional CHADS2 score in assessing afib stroke risk.⁴

12) Be cognizant of stent thrombosis and how to manage it.

Dr. Harold says that most hospitalists probably are up to date on drug-eluting stents and the risk of stopping dual antiplatelet therapy within several months of implant, but that doesn’t mean they won’t treat patients whose primary-care physicians (PCPs) aren’t up to date. He recommends working on these cases with hematologists.

“That knowledge is not widespread in terms of the internal-medicine community,” he says. “I’ve seen situations where patients have had their Plavix stopped for colonoscopies and they’ve had stent thrombosis. It’s this knowledge of cardiac patients who come in with recent deployment of drug-eluting stents who may end up having other issues.”

Tom Collins is a freelance writer in South Florida.

References

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119:1977-2016 an HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure. 2010;16(6):475-539.
2. Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297-298.
3. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.
4. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172-1179.
5. Associations between outpatient heart failure process-of-care measures and mortality. Circulation. 2011;123(15):1601-1610.

Only about a third of ideal candidates with heart failure are currently treated with [aldosterone antagonists], even though it markedly improves outcome and is Class I-recommended in the guidelines.

—Gregg Fonarow, MD, co-chief, University of California at Los Angeles division of cardiology, chair, American Heart Association’s Get With The Guidelines program steering committee

You might not have done a fellowship in cardiology, but quite often you probably feel like a cardiologist. Hospitalists frequently attend to patients on observation for heart problems and help manage even the most complex patients.

Often, you are working alongside the cardiologist. But other times, you’re on your own. Hospitalists are expected to carry an increasingly heavy load when it comes to heart-failure patients and many other kinds of patients with specialized disorders. It can be hard to keep up with what you need to know.

Top Twelve

1. Recognize the new importance of beta-blockers for heart failure, and go with the best of them.
2. It’s not readmissions that are the problem—it’s avoidable readmissions.
3. New interventional technologies will mean more complex patients, so be ready.
4. Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
5. Switching from IV diuretics to an oral regimen calls for careful monitoring.
6. Patients with heart failure with preserved ejection fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.
7. Inotropic agents can do more harm than good.
8. Pay attention to the ins and outs of new antiplatelet therapies.
9. Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.
10. Some non-STEMI patients might benefit from getting to the catheterization lab quickly.
11. Beware the idiosyncrasies of new anticoagulants.
12. Be cognizant of stent thrombosis and how to manage it.

The Hospitalist spoke to several cardiologists about the latest in treatments, technologies, and HM’s role in the system of care. The following are their suggestions for what you really need to know about treating patients with heart conditions.

1) Recognize the new importance of beta-blockers for heart failure, and go with the best of them.

Angiotensin converting enzyme inhibitors and angiotensive receptor blockers have been part of the Centers for Medicare & Medicaid Services’ (CMS) core measures for heart failure for a long time, but beta-blockers at hospital discharge only recently have been added as American College of Cardiology/American Heart Association/American Medical Association–Physician Consortium for Performance Improvement measures for heart failure.¹

“For those with heart failure and reduced left ventricular ejection fraction, very old and outdated concepts would have talked about potentially holding the beta-blocker during hospitalization for heart failure—or not initiating until the patient was an outpatient,” says Gregg Fonarow, MD, co-chief of the University of California at Los Angeles’ division of cardiology and chair of the steering committee for the American Heart Association’s Get With The Guidelines program. “[But] the guidelines and evidence, and often performance measures, linked to them are now explicit about initiating or maintaining beta-blockers during the heart-failure hospitalization.”

Beta-blockers should be initiated as patients are stabilized before discharge. Dr. Fonarow suggests hospitalists use only one of the three evidence-based therapies: carvedilol, metoprolol succinate, or bisoprolol.

“Many physicians have been using metoprolol tartrate or atenolol in heart-failure patients,” Dr. Fonarow says. “These are not known to improve clinical outcomes. So here’s an example where the specific medication is absolutely, critically important.”

2) It’s not readmissions that are the problem—it’s avoidable readmissions.

“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”

Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.² He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”

“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”

3) New interventional technologies will mean more complex patients, so be ready.

Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.

“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”

Many of these patients have other problems, including renal insufficiency, diabetes, and the like.

“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.

4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.

Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.

“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”

5) Switching from IV diuretics to an oral regimen calls for careful monitoring.

Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.

Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.

“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”

6) Patients with heart failure with preserved ejection

fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.

“We really can’t exercise a thought economy that just says, ‘Extrapolate the evidence-based therapies for heart failure with reduced ejection fraction to heart failure with preserved ejection fraction’ and expect good outcomes,” Dr. Yancy says. “That’s not the case. We don’t have an evidence base to substantiate that.”

He says one or more common comorbidities (e.g. atrial fibrillation, hypertension, obesity, diabetes, renal insufficiency) are present in 90% of patients with preserved ejection fraction. Treatment of those comorbidities—for example, rate control in afib patients, lowering the blood pressure in hypertension patients—has to be done with care.

“We should recognize that the therapy for this condition, albeit absent any specifically indicated interventions that will change its natural history, can still be skillfully constructed,” Dr. Yancy says. “But that construct needs to reflect the recommended, guideline-driven interventions for the concomitant other comorbidities.”

7) Inotropic agents can do more harm than good.

For patients who aren’t in cardiogenic shock, using inotropic agents doesn’t help. In fact, it might actually hurt. Dr. Fonarow says studies have shown these agents can “prolong length of stay, cause complications, and increase mortality risk.”

He notes that the use of inotropes should be avoided, or if it’s being considered, a cardiologist with knowledge and experience in heart failure should be involved in the treatment and care.

Statements about avoiding inotropes in heart failure, except under very specific circumstances, have been “incredibly strengthened” recently in the American College of Cardiology and Heart Failure Society of America guidelines.³

8) Pay attention to the ins and outs of new antiplatelet therapies.

For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event. There’s no simple antidote.

—John Harold, MD, president-elect, American College of Cardiology, former chief of staff, department of medicine, Cedars-Sinai Medical Center, Los Angeles

Hospitalists caring for acute coronary syndrome patients need to familiarize themselves with updated guidelines and additional therapies that are now available, Dr. Fonarow says. New antiplatelet therapies (e.g. prasugrel and ticagrelor) are available as part of the armamentarium, along with the mainstay clopidogrel.

“These therapies lower the risk of recurrent events, lowered the risk of stent thrombosis,” he says. “In the case of ticagrelor, it actually lowered all-cause mortality. These are important new therapies, with new guideline recommendations, that all hospitalists should be aware of.”

9) Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.

“Patients getting such devices as pacemakers or implantable cardioverter defribrillators (ICD) installed tend not to need bridging,” says Joaquin Cigarroa, MD, clinical chief of cardiology at Oregon Health & Science University in Portland.

He says it’s actually “safer” to do the procedure when patients “are on oral antithrombotics than switching them from an oral agent, and bridging with low- molecular-weight- or unfractionated heparin.”

“It’s a big deal,” Dr. Cigarroa adds, because it is risky to have elderly and frail patients on multiple antithrombotics. “Hemorrhagic complications in cardiology patients still occurs very frequently, so really be attuned to estimating bleeding risk and making sure that we’re dosing antithrombotics appropriately. Bridging should be the minority of patients, not the majority of patients.”

10) Some non-STEMI patients might benefit from getting to the catheterization lab quickly.

Door-to-balloon time is recognized as critical for ST-segment elevation myocardial infarction (STEMI) patients, but more recent work—such as in the TIMACS trial—finds benefits of early revascularization for some non-STEMI patients as well.²

“This trial showed that among higher-risk patients, using a validated risk score, that those patients did benefit from an early approach, meaning going to the cath lab in the first 12 hours of hospitalization,” Dr. Fonarow says. “We now have more information about the optimal timing of coronary angiography and potential revascularization of higher-risk patients with non-ST-segment elevation MI.”

11) Beware the idiosyncrasies of new anticoagulants.

The introduction of dabigatran and rivaroxaban (and, perhaps soon, apixaban) to the array of anticoagulant therapies brings a new slate of considerations for hospitalists, Dr. Harold says.

“For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event,” he says. “There’s no simple antidote. And the effect can last up to 12 to 24 hours, depending on the renal function. This is what the hospitalist will be called to deal with: bleeding complications in patients who have these newer anticoagulants on board.”

Dr. Fonarow says that the new CHA2DS2-VASc score has been found to do a better job than the traditional CHADS2 score in assessing afib stroke risk.⁴

12) Be cognizant of stent thrombosis and how to manage it.

Dr. Harold says that most hospitalists probably are up to date on drug-eluting stents and the risk of stopping dual antiplatelet therapy within several months of implant, but that doesn’t mean they won’t treat patients whose primary-care physicians (PCPs) aren’t up to date. He recommends working on these cases with hematologists.

“That knowledge is not widespread in terms of the internal-medicine community,” he says. “I’ve seen situations where patients have had their Plavix stopped for colonoscopies and they’ve had stent thrombosis. It’s this knowledge of cardiac patients who come in with recent deployment of drug-eluting stents who may end up having other issues.”

Tom Collins is a freelance writer in South Florida.

References

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119:1977-2016 an HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure. 2010;16(6):475-539.
2. Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297-298.
3. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.
4. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172-1179.
5. Associations between outpatient heart failure process-of-care measures and mortality. Circulation. 2011;123(15):1601-1610.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

An author of a report that estimates the national cost of unnecessary or wasteful healthcare at $750 billion per year hopes its findings will serve as a platform for hospitalists to spearhead improvements in healthcare delivery in the U.S.

The Institute of Medicine report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America" [PDF], offers 10 broad recommendations that include reforming payment, adopting digital infrastructure, and simplifying transitional care. The paper was published earlier this month by a national committee of healthcare leaders, including Gary Kaplan, MD, FACP, FACMPE, FACPE, chairman and chief executive officer of Virginia Mason Health System in Seattle.

"The hospitalist is in a very unique position," Dr. Kaplan says. "They really are at the nexus of what we see as several of our key recommendations going forward."

In particular, Dr. Kaplan notes that healthcare delivery organizations should develop, implement, and fine-tune their "systems, engineering tools and process-improvement methods." Making such changes would help to "eliminate inefficiencies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes," he says.

"The hospitalists and the care teams with which the hospitalist connects are very critical to streamlining operations," Dr. Kaplan adds.

Many of the report's complaints about unnecessary testing, poor communication, and inefficient care delivery dovetail with the quality initiatives and practice-management improvements HM groups already push, Dr. Kaplan adds. To advance healthcare delivery's evolution, hospitalists should view the task of reform as an opportunity, not a challenge.

"There are very powerful opportunities for the hospitalist now to have great impact," he says. "To not just be the passive participants in a broken and dysfunctional system, but in many ways, [to be] one of the architects of an improved care system going forward."

An author of a report that estimates the national cost of unnecessary or wasteful healthcare at $750 billion per year hopes its findings will serve as a platform for hospitalists to spearhead improvements in healthcare delivery in the U.S.

The Institute of Medicine report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America" [PDF], offers 10 broad recommendations that include reforming payment, adopting digital infrastructure, and simplifying transitional care. The paper was published earlier this month by a national committee of healthcare leaders, including Gary Kaplan, MD, FACP, FACMPE, FACPE, chairman and chief executive officer of Virginia Mason Health System in Seattle.

"The hospitalist is in a very unique position," Dr. Kaplan says. "They really are at the nexus of what we see as several of our key recommendations going forward."

In particular, Dr. Kaplan notes that healthcare delivery organizations should develop, implement, and fine-tune their "systems, engineering tools and process-improvement methods." Making such changes would help to "eliminate inefficiencies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes," he says.

"The hospitalists and the care teams with which the hospitalist connects are very critical to streamlining operations," Dr. Kaplan adds.

Many of the report's complaints about unnecessary testing, poor communication, and inefficient care delivery dovetail with the quality initiatives and practice-management improvements HM groups already push, Dr. Kaplan adds. To advance healthcare delivery's evolution, hospitalists should view the task of reform as an opportunity, not a challenge.

"There are very powerful opportunities for the hospitalist now to have great impact," he says. "To not just be the passive participants in a broken and dysfunctional system, but in many ways, [to be] one of the architects of an improved care system going forward."

An author of a report that estimates the national cost of unnecessary or wasteful healthcare at $750 billion per year hopes its findings will serve as a platform for hospitalists to spearhead improvements in healthcare delivery in the U.S.

The Institute of Medicine report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America" [PDF], offers 10 broad recommendations that include reforming payment, adopting digital infrastructure, and simplifying transitional care. The paper was published earlier this month by a national committee of healthcare leaders, including Gary Kaplan, MD, FACP, FACMPE, FACPE, chairman and chief executive officer of Virginia Mason Health System in Seattle.

"The hospitalist is in a very unique position," Dr. Kaplan says. "They really are at the nexus of what we see as several of our key recommendations going forward."

In particular, Dr. Kaplan notes that healthcare delivery organizations should develop, implement, and fine-tune their "systems, engineering tools and process-improvement methods." Making such changes would help to "eliminate inefficiencies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes," he says.

"The hospitalists and the care teams with which the hospitalist connects are very critical to streamlining operations," Dr. Kaplan adds.

Many of the report's complaints about unnecessary testing, poor communication, and inefficient care delivery dovetail with the quality initiatives and practice-management improvements HM groups already push, Dr. Kaplan adds. To advance healthcare delivery's evolution, hospitalists should view the task of reform as an opportunity, not a challenge.

"There are very powerful opportunities for the hospitalist now to have great impact," he says. "To not just be the passive participants in a broken and dysfunctional system, but in many ways, [to be] one of the architects of an improved care system going forward."

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

© Sean Locke/iStockphoto.com

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m² or higher (mean BMI 45.9 kg/m²), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

© Sean Locke/iStockphoto.com

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m² or higher (mean BMI 45.9 kg/m²), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

© Sean Locke/iStockphoto.com

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m² or higher (mean BMI 45.9 kg/m²), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

The Centers for Medicare & Medicaid Services' (CMS) recently announced final rule [PDF] on Stage 2 compliance for "meaningful use" of electronic health records (EHR) has been met with mixed reactions among most providers and trade groups, including SHM which voiced its concerns back in July.

"It's the classic government mixed bag," says Brenda Pawlak, director of Manatt Health Solutions, a division of New York City law firm Manatt, Phelps & Phillips.

Physician groups, including SHM and the Medical Group Management Association (MGMA), have lauded CMS for pushing back the implementation of Stage 2 meaningful-use requirements to 2014 from 2013. They also praised the agency for halving to 5% the percentage of a practice's patients who interact with an online portal. But for some providers, even the 5% threshold will be difficult to meet. And because physicians have to meet all requirements to qualify for incentive bonuses, the issue could loom large for specific groups.

"I don't think the 10% to 5% is a substantive change," Pawlak says.

Although most hospitalists are not directly subject to "meaningful use" requirements, many are heavily involved with assisting their institutions with implementation. SHM, which voiced its concerns in a July letter to CMS, is following this topic closely.

Some physician groups also lamented that the deadline for Stage 1 compliance remains unchanged at 2015. As physicians and provider groups attempt to comply with myriad rules, Pawlak says, meeting the 5% threshold will emerge as more burdensome as the deadline approaches. Still, CMS and federal officials say, the final rule will help nudge the healthcare system further into the digital age.

"The big message here is the push on standards-based interoperability of information," says Farzad Mostashari, MD, ScM, of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. "We are staying on course with the road map that we set in Stage 1."

The Centers for Medicare & Medicaid Services' (CMS) recently announced final rule [PDF] on Stage 2 compliance for "meaningful use" of electronic health records (EHR) has been met with mixed reactions among most providers and trade groups, including SHM which voiced its concerns back in July.

"It's the classic government mixed bag," says Brenda Pawlak, director of Manatt Health Solutions, a division of New York City law firm Manatt, Phelps & Phillips.

Physician groups, including SHM and the Medical Group Management Association (MGMA), have lauded CMS for pushing back the implementation of Stage 2 meaningful-use requirements to 2014 from 2013. They also praised the agency for halving to 5% the percentage of a practice's patients who interact with an online portal. But for some providers, even the 5% threshold will be difficult to meet. And because physicians have to meet all requirements to qualify for incentive bonuses, the issue could loom large for specific groups.

"I don't think the 10% to 5% is a substantive change," Pawlak says.

Although most hospitalists are not directly subject to "meaningful use" requirements, many are heavily involved with assisting their institutions with implementation. SHM, which voiced its concerns in a July letter to CMS, is following this topic closely.

Some physician groups also lamented that the deadline for Stage 1 compliance remains unchanged at 2015. As physicians and provider groups attempt to comply with myriad rules, Pawlak says, meeting the 5% threshold will emerge as more burdensome as the deadline approaches. Still, CMS and federal officials say, the final rule will help nudge the healthcare system further into the digital age.

"The big message here is the push on standards-based interoperability of information," says Farzad Mostashari, MD, ScM, of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. "We are staying on course with the road map that we set in Stage 1."

The Centers for Medicare & Medicaid Services' (CMS) recently announced final rule [PDF] on Stage 2 compliance for "meaningful use" of electronic health records (EHR) has been met with mixed reactions among most providers and trade groups, including SHM which voiced its concerns back in July.

"It's the classic government mixed bag," says Brenda Pawlak, director of Manatt Health Solutions, a division of New York City law firm Manatt, Phelps & Phillips.

Physician groups, including SHM and the Medical Group Management Association (MGMA), have lauded CMS for pushing back the implementation of Stage 2 meaningful-use requirements to 2014 from 2013. They also praised the agency for halving to 5% the percentage of a practice's patients who interact with an online portal. But for some providers, even the 5% threshold will be difficult to meet. And because physicians have to meet all requirements to qualify for incentive bonuses, the issue could loom large for specific groups.

"I don't think the 10% to 5% is a substantive change," Pawlak says.

Although most hospitalists are not directly subject to "meaningful use" requirements, many are heavily involved with assisting their institutions with implementation. SHM, which voiced its concerns in a July letter to CMS, is following this topic closely.

Some physician groups also lamented that the deadline for Stage 1 compliance remains unchanged at 2015. As physicians and provider groups attempt to comply with myriad rules, Pawlak says, meeting the 5% threshold will emerge as more burdensome as the deadline approaches. Still, CMS and federal officials say, the final rule will help nudge the healthcare system further into the digital age.

"The big message here is the push on standards-based interoperability of information," says Farzad Mostashari, MD, ScM, of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. "We are staying on course with the road map that we set in Stage 1."

Kerry Weiner, MD, acknowledges gaps in the continuity of care for many hospitalized patients, with the critical time being the first few days, or even hours, after leaving the hospital. The only provider who "really understands" what needs to happen next for the patient "is the hospitalist,” says Dr. Weiner, chief clinical officer for IPC The Hospitalist Co.

For the past decade, IPC has staffed a care-transitions call center at its corporate headquarters in North Hollywood, Calif. Twenty nurses, case managers, and patient representatives attempt to contact all patients discharged to home by IPC hospitalists within 48 to 72 hours.

According to data presented last December at an Institute for Healthcare Improvement national quality forum, IPC call centers reached out to nearly 350,000 patients discharged between October 2010 and September 2011. The calls were successful 30% of the time, and a fifth of the contacted patients needed an intervention. IPC calculates that those interventions prevented 1,782 avoidable readmissions.

According to Dr. Weiner, call center staff follow discharge instructions from the hospitalists using brief, customized, technology-driven reports. They focus on key points that could become health issues in the first few days after discharge.

IPC hopes to expand its care-transitions continuum, in part by prioritizing those patients who need to be called and reaching more of them, he adds.

Kerry Weiner, MD, acknowledges gaps in the continuity of care for many hospitalized patients, with the critical time being the first few days, or even hours, after leaving the hospital. The only provider who "really understands" what needs to happen next for the patient "is the hospitalist,” says Dr. Weiner, chief clinical officer for IPC The Hospitalist Co.

For the past decade, IPC has staffed a care-transitions call center at its corporate headquarters in North Hollywood, Calif. Twenty nurses, case managers, and patient representatives attempt to contact all patients discharged to home by IPC hospitalists within 48 to 72 hours.

According to data presented last December at an Institute for Healthcare Improvement national quality forum, IPC call centers reached out to nearly 350,000 patients discharged between October 2010 and September 2011. The calls were successful 30% of the time, and a fifth of the contacted patients needed an intervention. IPC calculates that those interventions prevented 1,782 avoidable readmissions.

According to Dr. Weiner, call center staff follow discharge instructions from the hospitalists using brief, customized, technology-driven reports. They focus on key points that could become health issues in the first few days after discharge.

IPC hopes to expand its care-transitions continuum, in part by prioritizing those patients who need to be called and reaching more of them, he adds.

Kerry Weiner, MD, acknowledges gaps in the continuity of care for many hospitalized patients, with the critical time being the first few days, or even hours, after leaving the hospital. The only provider who "really understands" what needs to happen next for the patient "is the hospitalist,” says Dr. Weiner, chief clinical officer for IPC The Hospitalist Co.

For the past decade, IPC has staffed a care-transitions call center at its corporate headquarters in North Hollywood, Calif. Twenty nurses, case managers, and patient representatives attempt to contact all patients discharged to home by IPC hospitalists within 48 to 72 hours.

According to data presented last December at an Institute for Healthcare Improvement national quality forum, IPC call centers reached out to nearly 350,000 patients discharged between October 2010 and September 2011. The calls were successful 30% of the time, and a fifth of the contacted patients needed an intervention. IPC calculates that those interventions prevented 1,782 avoidable readmissions.

According to Dr. Weiner, call center staff follow discharge instructions from the hospitalists using brief, customized, technology-driven reports. They focus on key points that could become health issues in the first few days after discharge.

IPC hopes to expand its care-transitions continuum, in part by prioritizing those patients who need to be called and reaching more of them, he adds.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.