Quality

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Nelson

Dr. Nelson

I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.

Grading Our Specialty

I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.

This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.

For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.

The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.

Grading Your HM Group

You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.

You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.

Discussion Document for Leadership

In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.

Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.

And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.

Where to Go from Here

The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.

There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Nelson

Dr. Nelson

I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.

Grading Our Specialty

I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.

This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.

For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.

The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.

Grading Your HM Group

You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.

You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.

Discussion Document for Leadership

In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.

Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.

And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.

Where to Go from Here

The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.

There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Nelson

Dr. Nelson

I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.

Grading Our Specialty

I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.

This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.

For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.

The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.

Grading Your HM Group

You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.

You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.

Discussion Document for Leadership

In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.

Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.

And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.

Where to Go from Here

The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.

There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.