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10 Choosing Wisely Recommendations by Specialists for Hospitalists
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
LISTEN NOW! ABIM Foundation EVP/COO Explains How the Choosing Wisely Campaign Got Started, and Its Impact on the U.S. Healthcare System
Listen to Daniel Wolfson explain how the Choosing Wisely campaign got started and its significance in U.S. healthcare
Listen to Daniel Wolfson explain how the Choosing Wisely campaign got started and its significance in U.S. healthcare
Listen to Daniel Wolfson explain how the Choosing Wisely campaign got started and its significance in U.S. healthcare
LISTEN NOW! Two Additional Choosing Wisely Recommendations from Specialty Societies
Listen to Dr. Cox, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., discuss why it's important for hospitalists to avoid diagnosing or managing asthma without spirometry.
Click here to listen to Dr. Shah, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, tell hospitalists why they should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
Listen to Dr. Cox, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., discuss why it's important for hospitalists to avoid diagnosing or managing asthma without spirometry.
Click here to listen to Dr. Shah, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, tell hospitalists why they should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
Listen to Dr. Cox, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., discuss why it's important for hospitalists to avoid diagnosing or managing asthma without spirometry.
Click here to listen to Dr. Shah, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, tell hospitalists why they should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
LISTEN NOW! UC San Francisco's Michelle Mourad Encourages Fellow Hospitalists To Get Involved in Quality Projects
Click here to listen to more of our interview with Dr. Mourad
Click here to listen to more of our interview with Dr. Mourad
Click here to listen to more of our interview with Dr. Mourad
Society of Hospital Medicine’s Hospitalist Program Peak Performance Sets Foundation for Improvement
SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.
The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.
“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.
“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”
Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.
Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.
“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”
HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.
“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.
She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”
Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.
As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.
“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”
SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.
The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.
“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.
“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”
Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.
Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.
“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”
HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.
“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.
She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”
Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.
As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.
“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”
SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.
The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.
“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.
“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”
Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.
Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.
“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”
HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.
“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.
She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”
Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.
As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.
“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”
Registration for ASHP’s Medication Safety Collaborative Still Open
Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.
Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.
SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.
Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.
The Medication Safety Collaborative consists of three meetings:
- ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
- The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
- Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.
Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.
Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.
SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.
Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.
The Medication Safety Collaborative consists of three meetings:
- ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
- The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
- Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.
Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.
Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.
SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.
Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.
The Medication Safety Collaborative consists of three meetings:
- ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
- The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
- Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.
Bill to Clarify Three-Midnight Rule for Medicare Patients Gains Support from Congress, Hospitalists
In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.
I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.
Support Is Growing
For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.
The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.
In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.
—Rep. Joe Courtney
Administrative Oversight
There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.
The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.
The impact on patients and families is tragic.
Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.
Three-Day Fix
While the problem of observation status treatment is complex, the solution is simple.
As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.
My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.
Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.
Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.
In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.
I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.
Support Is Growing
For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.
The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.
In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.
—Rep. Joe Courtney
Administrative Oversight
There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.
The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.
The impact on patients and families is tragic.
Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.
Three-Day Fix
While the problem of observation status treatment is complex, the solution is simple.
As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.
My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.
Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.
Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.
In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.
I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.
Support Is Growing
For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.
The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.
In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.
—Rep. Joe Courtney
Administrative Oversight
There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.
The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.
The impact on patients and families is tragic.
Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.
Three-Day Fix
While the problem of observation status treatment is complex, the solution is simple.
As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.
My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.
Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.
Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.
State of the Art
It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.
In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.
Here are some excerpts from my interview with Jason:
Question: What is an accountable care unit (ACU)?
Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.
Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?
A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.
Q: What makes an ACU successful?
A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.
SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.
—Jason Stein, MD, SFHM
Q: What is the biggest challenge in implementing and sustaining an ACU?
A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”
Naturally, not everyone immediately sees that they can gain rather than lose efficiency.
Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.
Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?
A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.
But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.
Q: How have ACUs performed so far?
A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.
The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.
Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?
A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”1
Q: Any final thoughts?
A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.
Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].
Reference
It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.
In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.
Here are some excerpts from my interview with Jason:
Question: What is an accountable care unit (ACU)?
Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.
Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?
A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.
Q: What makes an ACU successful?
A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.
SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.
—Jason Stein, MD, SFHM
Q: What is the biggest challenge in implementing and sustaining an ACU?
A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”
Naturally, not everyone immediately sees that they can gain rather than lose efficiency.
Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.
Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?
A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.
But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.
Q: How have ACUs performed so far?
A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.
The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.
Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?
A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”1
Q: Any final thoughts?
A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.
Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].
Reference
It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.
In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.
Here are some excerpts from my interview with Jason:
Question: What is an accountable care unit (ACU)?
Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.
Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?
A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.
Q: What makes an ACU successful?
A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.
SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.
—Jason Stein, MD, SFHM
Q: What is the biggest challenge in implementing and sustaining an ACU?
A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”
Naturally, not everyone immediately sees that they can gain rather than lose efficiency.
Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.
Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?
A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.
But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.
Q: How have ACUs performed so far?
A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.
The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.
Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?
A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”1
Q: Any final thoughts?
A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.
Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].
Reference
Quality Improvement, Patient Safety Top Hospitalists’ Priority Lists at HM14
LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.
Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.
“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”
Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.
Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”
After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”
John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”
“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”
Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.
“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.
He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.
“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”
In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.
An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.
“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”
Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.
“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”
One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.
“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”
The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.
And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.
“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”
LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.
Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.
“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”
Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.
Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”
After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”
John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”
“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”
Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.
“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.
He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.
“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”
In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.
An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.
“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”
Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.
“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”
One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.
“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”
The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.
And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.
“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”
LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.
Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.
“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”
Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.
Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”
After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”
John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”
“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”
Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.
“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.
He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.
“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”
In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.
An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.
“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”
Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.
“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”
One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.
“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”
The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.
And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.
“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”
HM14 Keynote Speakers Encourage Hospitalists to Deliver High-Quality, Low-Cost Patient Care
LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.
“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”
In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.
“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.
The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.
The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.
“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”
–Dr. Gottlieb
Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”
Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.
“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”
The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.
Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.
“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”
Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.
“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”
–Dr. Kealey
And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.
Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.
“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.
“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”
LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.
“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”
In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.
“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.
The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.
The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.
“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”
–Dr. Gottlieb
Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”
Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.
“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”
The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.
Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.
“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”
Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.
“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”
–Dr. Kealey
And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.
Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.
“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.
“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”
LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.
“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”
In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.
“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.
The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.
The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.
“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”
–Dr. Gottlieb
Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”
Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.
“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”
The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.
Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.
“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”
Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.
“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”
–Dr. Kealey
And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.
Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.
“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.
“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”