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Consider ‘impactibility’ to prevent hospital readmissions
With the goal of reducing 28-day or 30-day readmissions, some health care teams are turning to predictive models to identify patients at high risk for readmission and to efficiently focus resource-intensive prevention strategies. Recently, there’s been a rapid multiplying of these models.
Many of these models do accurately predict readmission risk, according to a recent BMJ editorial. “Among the 14 published models that target all unplanned readmissions (rather than readmissions for specific patient groups), the ‘C statistic’ ranges from 0.55 to 0.80, meaning that, when presented with two patients, these models correctly identify the higher risk individual between 55% and 80% of the time,” the authors wrote.
But, the authors suggested, the real value is not in simply making predictions but in using predictive models in ways that improve outcomes for patients.
“This will require linking predictive models to actionable opportunities for improving care,” they wrote. “Such linkages will most likely be identified through close collaboration between analytical teams, health care practitioners, and patients.” Being at high risk of readmission is not the only consideration; the patient must also be able to benefit from interventions being considered – they must be “impactible.”
“The distinction between predictive risk and impactibility might explain why practitioners tend to identify quite different patients for intervention than predictive risk models,” the authors wrote.
But together, predictive models and clinicians might produce more effective decisions than either does alone. “One of the strengths of predictive models is that they produce objective and consistent judgments regarding readmission risk, whereas clinical judgment can be affected by personal attitudes or attentiveness. Predictive risk models can also be operationalised across whole populations, and might therefore identify needs that would otherwise be missed by clinical teams (e.g., among more socioeconomically deprived neighbourhoods or groups with inadequate primary care). On the other hand, clinicians have access to a much wider range of information regarding patients than predictive risk models, which is essential to judge impactibility.”
The authors conclude, “The predictive modelling enterprise would benefit enormously from such collaboration because the real goal of this activity lies not in predicting the risk of readmission but in identifying patients at risk for preventable readmissions and ‘impactible’ by available interventions.”
Reference
Steventon A et al. Preventing hospital readmissions: The importance of considering ‘impactibility,’ not just predicted risk. BMJ Qual Saf. 2017 Oct;26(10):782-5. Accessed Oct. 9, 2017.
With the goal of reducing 28-day or 30-day readmissions, some health care teams are turning to predictive models to identify patients at high risk for readmission and to efficiently focus resource-intensive prevention strategies. Recently, there’s been a rapid multiplying of these models.
Many of these models do accurately predict readmission risk, according to a recent BMJ editorial. “Among the 14 published models that target all unplanned readmissions (rather than readmissions for specific patient groups), the ‘C statistic’ ranges from 0.55 to 0.80, meaning that, when presented with two patients, these models correctly identify the higher risk individual between 55% and 80% of the time,” the authors wrote.
But, the authors suggested, the real value is not in simply making predictions but in using predictive models in ways that improve outcomes for patients.
“This will require linking predictive models to actionable opportunities for improving care,” they wrote. “Such linkages will most likely be identified through close collaboration between analytical teams, health care practitioners, and patients.” Being at high risk of readmission is not the only consideration; the patient must also be able to benefit from interventions being considered – they must be “impactible.”
“The distinction between predictive risk and impactibility might explain why practitioners tend to identify quite different patients for intervention than predictive risk models,” the authors wrote.
But together, predictive models and clinicians might produce more effective decisions than either does alone. “One of the strengths of predictive models is that they produce objective and consistent judgments regarding readmission risk, whereas clinical judgment can be affected by personal attitudes or attentiveness. Predictive risk models can also be operationalised across whole populations, and might therefore identify needs that would otherwise be missed by clinical teams (e.g., among more socioeconomically deprived neighbourhoods or groups with inadequate primary care). On the other hand, clinicians have access to a much wider range of information regarding patients than predictive risk models, which is essential to judge impactibility.”
The authors conclude, “The predictive modelling enterprise would benefit enormously from such collaboration because the real goal of this activity lies not in predicting the risk of readmission but in identifying patients at risk for preventable readmissions and ‘impactible’ by available interventions.”
Reference
Steventon A et al. Preventing hospital readmissions: The importance of considering ‘impactibility,’ not just predicted risk. BMJ Qual Saf. 2017 Oct;26(10):782-5. Accessed Oct. 9, 2017.
With the goal of reducing 28-day or 30-day readmissions, some health care teams are turning to predictive models to identify patients at high risk for readmission and to efficiently focus resource-intensive prevention strategies. Recently, there’s been a rapid multiplying of these models.
Many of these models do accurately predict readmission risk, according to a recent BMJ editorial. “Among the 14 published models that target all unplanned readmissions (rather than readmissions for specific patient groups), the ‘C statistic’ ranges from 0.55 to 0.80, meaning that, when presented with two patients, these models correctly identify the higher risk individual between 55% and 80% of the time,” the authors wrote.
But, the authors suggested, the real value is not in simply making predictions but in using predictive models in ways that improve outcomes for patients.
“This will require linking predictive models to actionable opportunities for improving care,” they wrote. “Such linkages will most likely be identified through close collaboration between analytical teams, health care practitioners, and patients.” Being at high risk of readmission is not the only consideration; the patient must also be able to benefit from interventions being considered – they must be “impactible.”
“The distinction between predictive risk and impactibility might explain why practitioners tend to identify quite different patients for intervention than predictive risk models,” the authors wrote.
But together, predictive models and clinicians might produce more effective decisions than either does alone. “One of the strengths of predictive models is that they produce objective and consistent judgments regarding readmission risk, whereas clinical judgment can be affected by personal attitudes or attentiveness. Predictive risk models can also be operationalised across whole populations, and might therefore identify needs that would otherwise be missed by clinical teams (e.g., among more socioeconomically deprived neighbourhoods or groups with inadequate primary care). On the other hand, clinicians have access to a much wider range of information regarding patients than predictive risk models, which is essential to judge impactibility.”
The authors conclude, “The predictive modelling enterprise would benefit enormously from such collaboration because the real goal of this activity lies not in predicting the risk of readmission but in identifying patients at risk for preventable readmissions and ‘impactible’ by available interventions.”
Reference
Steventon A et al. Preventing hospital readmissions: The importance of considering ‘impactibility,’ not just predicted risk. BMJ Qual Saf. 2017 Oct;26(10):782-5. Accessed Oct. 9, 2017.
New curriculum teaches value-based health care
While value has become an imperative in both training and health care delivery, few tools exist to teach hospitalists and other providers the basic concepts of value.
“Hospitalists are on the front lines of health care value delivery, and it is critical that we understand and embrace the concepts of value; however, we also need to be able to deliver upon these ideals,” said Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin.
Dr. Moriates developed a free online core curriculum called “Discovering Value-Based Health Care.” “We built ‘Discovering Value-Based Health Care’ to serve as an adaptive learning resource for clinicians at all levels – from medical school through practicing physicians,” he said. The first module, “There’s a Better Way,” is available now.
“As a hospitalist, I ensured that the content would be specifically applicable to our day-to-day world and experience,” Dr. Moriates said. “Using the modules, hospitalists can better understand how emerging tools, such as the University of Utah’s Value-Drive Outcome tool, can be used by hospitalists to improve value. The modules also dig into thorny subjects like understanding health care costs – for example, what really is the difference between costs and charges?”
The course is adaptive and interactive, using the latest in instructional technology, he said. Hospitalists can take the course independently and earn free CME credits; those who complete all three modules in this first collection will receive a certificate of completion and CME credit.
The goal is to release 10 modules over the course of this academic year, Dr. Moriates said. Future collections will cover “value-based health care delivery,” “how to deliver high-value care at the bedside,” and “how to deliver high-value care in systems.”
“As value-based health care is increasingly taught in medical schools and residency training, it is important for hospitalists – especially any of us that work with trainees – to be able to speak the same language and understand what our trainees now will know,” he said.
While value has become an imperative in both training and health care delivery, few tools exist to teach hospitalists and other providers the basic concepts of value.
“Hospitalists are on the front lines of health care value delivery, and it is critical that we understand and embrace the concepts of value; however, we also need to be able to deliver upon these ideals,” said Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin.
Dr. Moriates developed a free online core curriculum called “Discovering Value-Based Health Care.” “We built ‘Discovering Value-Based Health Care’ to serve as an adaptive learning resource for clinicians at all levels – from medical school through practicing physicians,” he said. The first module, “There’s a Better Way,” is available now.
“As a hospitalist, I ensured that the content would be specifically applicable to our day-to-day world and experience,” Dr. Moriates said. “Using the modules, hospitalists can better understand how emerging tools, such as the University of Utah’s Value-Drive Outcome tool, can be used by hospitalists to improve value. The modules also dig into thorny subjects like understanding health care costs – for example, what really is the difference between costs and charges?”
The course is adaptive and interactive, using the latest in instructional technology, he said. Hospitalists can take the course independently and earn free CME credits; those who complete all three modules in this first collection will receive a certificate of completion and CME credit.
The goal is to release 10 modules over the course of this academic year, Dr. Moriates said. Future collections will cover “value-based health care delivery,” “how to deliver high-value care at the bedside,” and “how to deliver high-value care in systems.”
“As value-based health care is increasingly taught in medical schools and residency training, it is important for hospitalists – especially any of us that work with trainees – to be able to speak the same language and understand what our trainees now will know,” he said.
While value has become an imperative in both training and health care delivery, few tools exist to teach hospitalists and other providers the basic concepts of value.
“Hospitalists are on the front lines of health care value delivery, and it is critical that we understand and embrace the concepts of value; however, we also need to be able to deliver upon these ideals,” said Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin.
Dr. Moriates developed a free online core curriculum called “Discovering Value-Based Health Care.” “We built ‘Discovering Value-Based Health Care’ to serve as an adaptive learning resource for clinicians at all levels – from medical school through practicing physicians,” he said. The first module, “There’s a Better Way,” is available now.
“As a hospitalist, I ensured that the content would be specifically applicable to our day-to-day world and experience,” Dr. Moriates said. “Using the modules, hospitalists can better understand how emerging tools, such as the University of Utah’s Value-Drive Outcome tool, can be used by hospitalists to improve value. The modules also dig into thorny subjects like understanding health care costs – for example, what really is the difference between costs and charges?”
The course is adaptive and interactive, using the latest in instructional technology, he said. Hospitalists can take the course independently and earn free CME credits; those who complete all three modules in this first collection will receive a certificate of completion and CME credit.
The goal is to release 10 modules over the course of this academic year, Dr. Moriates said. Future collections will cover “value-based health care delivery,” “how to deliver high-value care at the bedside,” and “how to deliver high-value care in systems.”
“As value-based health care is increasingly taught in medical schools and residency training, it is important for hospitalists – especially any of us that work with trainees – to be able to speak the same language and understand what our trainees now will know,” he said.
Managing mental health care at the hospital
The numbers tell a grim story. Nationwide, 43.7 million adult Americans experienced a mental health condition during 2016 – an increase of 1.2 million over the previous year. Mental health issues send almost 5.5 million people to emergency departments each year; nearly 60% of adults with a mental illness received no treatment at all.
If that massive – and growing – need is one side of the story, shrinking resources are the other. Mental health resources had already been diminishing for decades before the recession hit – and hit them especially hard. Between 2009 and 2012, states cut $5 billion in mental health services; during that time, at least 4,500 public psychiatric hospital beds nationwide disappeared – nearly 10% of the total supply. The bulk of those resources have never been restored.
Provider numbers also are falling. “Psychiatry is probably the top manpower shortage among all specialties,” said Joe Parks, MD, medical director of the National Council for Behavioral Health. “We have about a third the number of psychiatrists that most estimates say we need, and the number per capita is decreasing.” A significant percentage of psychiatrists – more than 50% – only accept cash, bypassing the low reimbursement rates even private insurance typically offers.
This is all evidence of our broad unwillingness, as a society, to invest in mental health, said Teresa Nguyen, LCSW, vice president of policy and programs at Mental Health America. “If we can’t reimburse people fairly for doing really important work, we’re not going to drive up the demand for more people to think about how to better serve people from a mental health perspective.”
Hospitals, of course, feel those financial disincentives too, which discourage them from investments of their own. “It’s a difficult population to manage, and it’s difficult to manage the financial realities of mental health as well,” said John McHugh, PhD, assistant professor of health policy at Columbia University, New York. “If you were a hospital administrator looking to invest your last dollar and you have the option of investing it in a new heart institute or in behavioral health service, more likely than not, you’re going to invest it in the more profitable cardiovascular service line.”
Providers of last resort
But much of the burden of caring for this population ends up falling on hospitals by default. At Denver Health, Melanie Rylander, MD, medical director of the inpatient psychiatric unit, reports seeing this manifest in three categories of patients. First, there is an influx of people coming into the emergency department with primary mental health issues.
“We’re also seeing an influx of people coming in with physical problems, and upon assessment it becomes very clear very quickly that the real issue is an underlying mental health issue,” she said. Then there are the people coming in for the same physical problems over and over – maybe decompensated heart failure or COPD exacerbations – because mental health issues are impeding their ability to take care of themselves.
Some hospitalists say they feel ill equipped to care for these patients. “We don’t have the facility or the resources many times to properly care for their psychiatric needs when they’re in the hospital. It’s not really part of an internist’s training to be familiar with a lot of the medications,” said Atashi Mandal, MD, a hospitalist and pediatrician in Los Angeles. “Sometimes they get improperly medicated because we don’t know what else to do and the patient’s behavioral issues are escalating, so it’s really a difficult position.”
It’s a dispiriting experience for a hospitalist. “It really bothers me when I am trying to care for a patient who has psychiatric needs, and I feel I’m not able to do it, and I can’t find resources, and I feel that this patient’s needs are being neglected – not because we don’t care, and not because of a lack of effort by the staff. It’s just set up to fail,” Dr. Mandal said.
Ending the silo mentality
Encouraging a more holistic view of health across health care would be an important step to begin to address the problem – after all, the mind and the body are not separate.
“We work in silos, and we really have to stop doing that because these are intertwined,” said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “A schizophrenic will become worse when they’re medically ill. That illness will be harder to treat if their psychiatric illness is active.” This is starting to happen in the outpatient setting, evidenced by the expansion of the integrated care model, where a primary care doctor is the lead physician working in combination with psychologists, psychiatrists, and social workers. Communication among providers becomes simpler, and patients don’t fall through the cracks as often while trying to navigate the system.
“How do we promote even more of that? If we make things easier for patients and increase the odds of compliance, then maybe they won’t need to go to the hospital,” Dr. Karlin-Zysman said. “Patients with behavioral health issues are just not getting the level of care and attention they need, and we have to figure it out. They’re going to be a bigger and bigger proportion of patients that we’re going to see in the hospital setting, but it doesn’t have to be dealt with in the hospital setting if it’s better treated in the outpatient setting.”
That idea of integration is also making its way into the hospital setting in various ways. In their efforts to bring the care to the patient, rather than the other way around, Dr. Karlin-Zysman’s hospital embedded two hospitalists in the neighboring inpatient psychiatric hospital; when patients need medical treatment, they can receive it without interrupting their behavioral health treatment. As a result, patients who used to end up in their emergency department don’t anymore, and their 30-day readmission rate has fallen by 50%.
But at its foundation, care integration is more of an attitude than a system; it begins with a mindset.
“We talk so much today about system reform, integrated systems, blah, blah,” said Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston. “I don’t want to make it seem like it’s not going to work, but what does it mean for the patient who is psychotic and has 10 problems, with whom you have 15 minutes? Taking good care of these patients means you have to take a deep breath and put in a lot of time and deal with all these things that have nothing to do with the health system under which you practice. There’s this ‘only so much you can do’ feeling that is a problem in itself, because there’s actually a lot we can do.”
Hospitals and communities
It’s axiomatic to say that a better approach to mental health would be based around prevention and early intervention, rather than the less crisis-oriented system we have now. Some efforts are being made in that direction, and they involve, and require, outreach outside the hospital.
“The best hospitals doing work in mental health are going beyond the hospital walls; they’re really looking at their community,” Dr. Nguyen said. “You have hospitals, like Accountable Care Organizations, who are trying to move earlier and think about mental health from a pediatric standpoint: How can we support parents and children during critical phases of brain growth? How can we provide prevention services?” Ultimately, those efforts should help lower future admission rates to EDs and hospitals.
That forward-looking approach may be necessary, but it’s also a challenge. “As a hospital administrator, I would think that you look out at the community and see this problem is not going away – in fact, it is likely going to get worse,” Dr. McHugh said. “A health system may look at themselves and say we have to take the lead on this.” The difficulty is that thinking of it in a sense of value to the community, and making the requisite investments, will have a very long period of payout; a health system that’s struggling may not be able to do it. “It’s the large [health systems] that tend to be more integrated … that are thinking about this much differently,” he said.
Still, the reality is that’s where the root of the problem lies, Dr. Rylander said – not in the hospital, but in the larger community. “In the absence of very basic needs – stable housing, food, heating – it’s really not reasonable to expect that people are going to take care of their physical needs,” she said. “It’s a much larger social issue: how to get resources so that these people can have stable places to live, they can get to and from appointments, that type of thing.”
Those needs are ongoing, of course. Many of these patients suffer from chronic conditions, meaning people will continue to need services and support, said Ron Honberg, JD, senior policy adviser for the National Alliance on Mental Illness. Often, people need services from different systems. “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on the providers of last resort, and that includes hospitals,” he said.
A collaborative effort may be needed, but hospitals can still be active participants and even leaders.
“If hospitals really want to address these problems, they need to be part of the discussions taking place in communities among the various systems and providers and advocates,” Mr. Honberg said. “Ultimately, we need to develop a better community-based system of care, and a better way of handing people off from inpatient to community-based treatment, and some accountability in terms of requiring that people get services, so they don’t get rehospitalized quickly. You’re increasingly seeing accountability now with other health conditions; we’re measuring things in Medicare like rehospitalization rates and the like. We need to be doing that with mental health treatment as well.”
What a hospitalist can do
One thing hospitalists might consider is starting that practice at their own hospitals, measuring, recording, and sharing that kind of information.
“Hospitalists should measure systematically, and in a very neutral manner, the total burden and frequency of the problem and report it consistently to management, along with their assessment that this impairs the quality of care and creates patient risk,” Dr. Parks said. That information can help hospitalists lobby for access to psychiatric personnel, be that in person or through telemedicine. “We don’t have to lay hands on you. There’s no excuse for any hospital not having a contract in place for on-demand consultation in the ER and on the floors.”
Track outcomes, too, Dr. Mandal suggests. With access to the right personnel, are you getting patients out of the ED faster? Are you having fewer negative outcomes while these patients are in the hospital, such as having to use restraints or get security involved? “Hopefully you can get some data in terms of how much money you’ve saved by decreasing the length of stays and decreasing inadvertent adverse effects because the patients weren’t receiving the proper care,” he said.
As this challenge seems likely to continue to grow, hospitalists might consider finding more training in mental health issues themselves so they are more comfortable handling these issues, Dr. Parks said. “The average mini-psych rotation from medical school is only 4 weeks,” he noted. “The ob.gyn. is at least 8 weeks and often 12 weeks, and if you don’t go into ob.gyn., you’re going to see a lot more mentally ill people through the rest of your practice, no matter what you do, than you are going to see pregnant women.”
Just starting these conversations – with patients, with colleagues, with family and friends – might be the most important change of all. “Even though nobody is above these issues afflicting them, this is still something that is not part of an open dialogue, and this is something that affects our own colleagues,” Dr. Mandal said. “I don’t know how many more trainees jumping out of windows it will take, or colleagues going through depression and feeling that it’s a sign of weakness to even talk about it.
“We need to create safe harbors within our own medical communities and acknowledge that we ourselves can be prone to this,” he said. “Perhaps by doing that, we will develop more empathy and become more comfortable, not just with ourselves and our colleagues but also helping these patients. People get overwhelmed and throw their hands up because it is just such a difficult issue. I don’t want people to give up, both from the medical community and our society as a whole – we can’t give up.”
A med-psych unit pilot project
Med-psych units can be a good model to take on these challenges. At Long Island Jewish Medical Center, they launched a pilot project to see how one would work in their community and summarized the results in an SHM abstract.
The hospital shares a campus with a 200-bed inpatient psych hospital, and doctors were seeing a lot of back and forth between the two institutions, said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “Patients would come into the hospital because they had an active medical issue, but because of their behavioral issues, they’d have to have continuous observation. It would not be uncommon for us to have sometimes close to 30 patients who needed 24-hour continuous observation to make sure they were not hurting themselves.” These PCAs or nurse’s assistants were doing 8-hour shifts, so each patient needed three. “The math is staggering – and with not any better outcomes.”
So the hospital created a 15-bed closed med-psych unit for medically ill patients with behavioral health disorders. They staffed it with a dedicated hospitalist, a nurse practitioner, a psychologist, and a nurse manager.
The number of patients requiring continuous observation fell to single digits. Once in their own unit, these patients caused less disruption and stress on the medical units. They had a lower length of stay compared to their previous admissions in other units, and this became one of the hospital’s highest performing units in terms of patient experience.
The biggest secret of their success, Dr. Karlin-Zysman said, is cohorting. “Instead of them going to the next open bed, wherever it may be, you get the patients all in one place geographically, with a team trained to manage those patients.” Another factor: it’s a hospitalist-run unit. “You can’t have 20 different doctors taking care of the patients; it’s one or two hospitalists running this unit.”
Care models like this can be a true win-win, and her hospital is using them more and more.
“I have a care model that’s a stroke unit; I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. “We’re creating these true teams, which I think hospitalists really like being part of. What’s that thing that makes them want to come to work every day? Things like this: running a care model, becoming specialized in something.” There are research and abstract opportunities for hospitalists on these units too, which also helps keep them engaged, she said. “I’ve used this care model and things like that to reduce burnout and keep people excited.”
The persistent mortality gap
Patients with mental illness tend to receive worse medical care than people without, studies have shown; they die an average of 25 years earlier, largely from preventable or treatable conditions such as cardiovascular disease and diabetes. The World Health Organization has called the problem “a hidden human rights emergency.”
In one in a series of articles on mental health, Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston, raises the question: Might physician attitudes toward mentally ill people contribute to this mortality gap, and if so, can we change them?
She recognizes the many obstacles physicians face in treating these patients. “The medicines we have are good but not great and can cause obesity and diabetes, which contributes to cardiovascular morbidity and mortality,” Dr. Rosenbaum said. “We have the adherence challenge for the psychiatric medications and for medications for chronic disease. It’s hard enough for anyone to take a medicine every day, and to do that if you’re homeless or you don’t have insight into the need for it, it’s really hard.”
Also, certain behaviors that are more common among people with serious mental illness – smoking, substance abuse, physical inactivity – increase their risk for chronic diseases.
These hurdles may foster a sense of helplessness among hospitalists who have just a small amount of time to spend with a patient, and attitudes may be hard to change.
“Negotiating more effectively about care refusals, more adeptly assessing capacity, and recognizing when our efforts to orchestrate care have been inadequate seem feasible,” Dr. Rosenbaum writes. “Far harder is overcoming any collective belief that what mentally ill people truly need is not something we can offer.” That’s why a truly honest examination of attitudes and biases is a necessary place to start.
She tells the story of one mentally ill patient she learned of in her research, who, after decades as the quintessential frequent flier in the ER, was living stably in the community. “No one could have known how many tries it would take to help him get there,” she writes. His doctor told her, “Let’s say 10 attempts are necessary. Someone needs to be number 2, 3 and 7. You just never know which number you are.”
Education for physicians
A course created by the National Alliance on Mental Illness addresses mental illness issues from a provider perspective.
“Although the description states that the course is intended for mental health professionals, it can be and has been used to educate and inform other healthcare professionals as well,” said Ron Honberg, JD, senior policy advisor for the National Alliance on Mental Illness. The standard course takes 15 hours; there is an abbreviated 4-hour alternative as well. More information can be found at http://www.nami.org/Find-Support/NAMI-Programs/NAMI-Provider-Education.
Sources
1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/. Accessed March 10, 2017.
2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/state-mental-health-america. Accessed March 30, 2017.
3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a Hybrid Medicine and Psychiatric Unit to Manage Medically Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http://www.shmabstracts.com/abstract/creating-a-hybrid-medicine-and-psychiatric-unit-to-manage-medically-ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017.
4. Garey J. When Doctors Discriminate. New York Times. http://www.nytimes.com/2013/08/11/opinion/sunday/when-doctors-discriminate.html. August 10, 2013. Accessed March 15, 2017.
5. Rosenbaum L. Closing the Mortality Gap – Mental Illness and Medical Care. N Engl J Med. 2016; 375:1585-1589. doi: 10.1056/NEJMms1610125.
6. Rosenbaum L. Unlearning Our Helplessness – Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016;375:1690-4. doi: 10.1056/NEJMms1610127.
The numbers tell a grim story. Nationwide, 43.7 million adult Americans experienced a mental health condition during 2016 – an increase of 1.2 million over the previous year. Mental health issues send almost 5.5 million people to emergency departments each year; nearly 60% of adults with a mental illness received no treatment at all.
If that massive – and growing – need is one side of the story, shrinking resources are the other. Mental health resources had already been diminishing for decades before the recession hit – and hit them especially hard. Between 2009 and 2012, states cut $5 billion in mental health services; during that time, at least 4,500 public psychiatric hospital beds nationwide disappeared – nearly 10% of the total supply. The bulk of those resources have never been restored.
Provider numbers also are falling. “Psychiatry is probably the top manpower shortage among all specialties,” said Joe Parks, MD, medical director of the National Council for Behavioral Health. “We have about a third the number of psychiatrists that most estimates say we need, and the number per capita is decreasing.” A significant percentage of psychiatrists – more than 50% – only accept cash, bypassing the low reimbursement rates even private insurance typically offers.
This is all evidence of our broad unwillingness, as a society, to invest in mental health, said Teresa Nguyen, LCSW, vice president of policy and programs at Mental Health America. “If we can’t reimburse people fairly for doing really important work, we’re not going to drive up the demand for more people to think about how to better serve people from a mental health perspective.”
Hospitals, of course, feel those financial disincentives too, which discourage them from investments of their own. “It’s a difficult population to manage, and it’s difficult to manage the financial realities of mental health as well,” said John McHugh, PhD, assistant professor of health policy at Columbia University, New York. “If you were a hospital administrator looking to invest your last dollar and you have the option of investing it in a new heart institute or in behavioral health service, more likely than not, you’re going to invest it in the more profitable cardiovascular service line.”
Providers of last resort
But much of the burden of caring for this population ends up falling on hospitals by default. At Denver Health, Melanie Rylander, MD, medical director of the inpatient psychiatric unit, reports seeing this manifest in three categories of patients. First, there is an influx of people coming into the emergency department with primary mental health issues.
“We’re also seeing an influx of people coming in with physical problems, and upon assessment it becomes very clear very quickly that the real issue is an underlying mental health issue,” she said. Then there are the people coming in for the same physical problems over and over – maybe decompensated heart failure or COPD exacerbations – because mental health issues are impeding their ability to take care of themselves.
Some hospitalists say they feel ill equipped to care for these patients. “We don’t have the facility or the resources many times to properly care for their psychiatric needs when they’re in the hospital. It’s not really part of an internist’s training to be familiar with a lot of the medications,” said Atashi Mandal, MD, a hospitalist and pediatrician in Los Angeles. “Sometimes they get improperly medicated because we don’t know what else to do and the patient’s behavioral issues are escalating, so it’s really a difficult position.”
It’s a dispiriting experience for a hospitalist. “It really bothers me when I am trying to care for a patient who has psychiatric needs, and I feel I’m not able to do it, and I can’t find resources, and I feel that this patient’s needs are being neglected – not because we don’t care, and not because of a lack of effort by the staff. It’s just set up to fail,” Dr. Mandal said.
Ending the silo mentality
Encouraging a more holistic view of health across health care would be an important step to begin to address the problem – after all, the mind and the body are not separate.
“We work in silos, and we really have to stop doing that because these are intertwined,” said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “A schizophrenic will become worse when they’re medically ill. That illness will be harder to treat if their psychiatric illness is active.” This is starting to happen in the outpatient setting, evidenced by the expansion of the integrated care model, where a primary care doctor is the lead physician working in combination with psychologists, psychiatrists, and social workers. Communication among providers becomes simpler, and patients don’t fall through the cracks as often while trying to navigate the system.
“How do we promote even more of that? If we make things easier for patients and increase the odds of compliance, then maybe they won’t need to go to the hospital,” Dr. Karlin-Zysman said. “Patients with behavioral health issues are just not getting the level of care and attention they need, and we have to figure it out. They’re going to be a bigger and bigger proportion of patients that we’re going to see in the hospital setting, but it doesn’t have to be dealt with in the hospital setting if it’s better treated in the outpatient setting.”
That idea of integration is also making its way into the hospital setting in various ways. In their efforts to bring the care to the patient, rather than the other way around, Dr. Karlin-Zysman’s hospital embedded two hospitalists in the neighboring inpatient psychiatric hospital; when patients need medical treatment, they can receive it without interrupting their behavioral health treatment. As a result, patients who used to end up in their emergency department don’t anymore, and their 30-day readmission rate has fallen by 50%.
But at its foundation, care integration is more of an attitude than a system; it begins with a mindset.
“We talk so much today about system reform, integrated systems, blah, blah,” said Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston. “I don’t want to make it seem like it’s not going to work, but what does it mean for the patient who is psychotic and has 10 problems, with whom you have 15 minutes? Taking good care of these patients means you have to take a deep breath and put in a lot of time and deal with all these things that have nothing to do with the health system under which you practice. There’s this ‘only so much you can do’ feeling that is a problem in itself, because there’s actually a lot we can do.”
Hospitals and communities
It’s axiomatic to say that a better approach to mental health would be based around prevention and early intervention, rather than the less crisis-oriented system we have now. Some efforts are being made in that direction, and they involve, and require, outreach outside the hospital.
“The best hospitals doing work in mental health are going beyond the hospital walls; they’re really looking at their community,” Dr. Nguyen said. “You have hospitals, like Accountable Care Organizations, who are trying to move earlier and think about mental health from a pediatric standpoint: How can we support parents and children during critical phases of brain growth? How can we provide prevention services?” Ultimately, those efforts should help lower future admission rates to EDs and hospitals.
That forward-looking approach may be necessary, but it’s also a challenge. “As a hospital administrator, I would think that you look out at the community and see this problem is not going away – in fact, it is likely going to get worse,” Dr. McHugh said. “A health system may look at themselves and say we have to take the lead on this.” The difficulty is that thinking of it in a sense of value to the community, and making the requisite investments, will have a very long period of payout; a health system that’s struggling may not be able to do it. “It’s the large [health systems] that tend to be more integrated … that are thinking about this much differently,” he said.
Still, the reality is that’s where the root of the problem lies, Dr. Rylander said – not in the hospital, but in the larger community. “In the absence of very basic needs – stable housing, food, heating – it’s really not reasonable to expect that people are going to take care of their physical needs,” she said. “It’s a much larger social issue: how to get resources so that these people can have stable places to live, they can get to and from appointments, that type of thing.”
Those needs are ongoing, of course. Many of these patients suffer from chronic conditions, meaning people will continue to need services and support, said Ron Honberg, JD, senior policy adviser for the National Alliance on Mental Illness. Often, people need services from different systems. “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on the providers of last resort, and that includes hospitals,” he said.
A collaborative effort may be needed, but hospitals can still be active participants and even leaders.
“If hospitals really want to address these problems, they need to be part of the discussions taking place in communities among the various systems and providers and advocates,” Mr. Honberg said. “Ultimately, we need to develop a better community-based system of care, and a better way of handing people off from inpatient to community-based treatment, and some accountability in terms of requiring that people get services, so they don’t get rehospitalized quickly. You’re increasingly seeing accountability now with other health conditions; we’re measuring things in Medicare like rehospitalization rates and the like. We need to be doing that with mental health treatment as well.”
What a hospitalist can do
One thing hospitalists might consider is starting that practice at their own hospitals, measuring, recording, and sharing that kind of information.
“Hospitalists should measure systematically, and in a very neutral manner, the total burden and frequency of the problem and report it consistently to management, along with their assessment that this impairs the quality of care and creates patient risk,” Dr. Parks said. That information can help hospitalists lobby for access to psychiatric personnel, be that in person or through telemedicine. “We don’t have to lay hands on you. There’s no excuse for any hospital not having a contract in place for on-demand consultation in the ER and on the floors.”
Track outcomes, too, Dr. Mandal suggests. With access to the right personnel, are you getting patients out of the ED faster? Are you having fewer negative outcomes while these patients are in the hospital, such as having to use restraints or get security involved? “Hopefully you can get some data in terms of how much money you’ve saved by decreasing the length of stays and decreasing inadvertent adverse effects because the patients weren’t receiving the proper care,” he said.
As this challenge seems likely to continue to grow, hospitalists might consider finding more training in mental health issues themselves so they are more comfortable handling these issues, Dr. Parks said. “The average mini-psych rotation from medical school is only 4 weeks,” he noted. “The ob.gyn. is at least 8 weeks and often 12 weeks, and if you don’t go into ob.gyn., you’re going to see a lot more mentally ill people through the rest of your practice, no matter what you do, than you are going to see pregnant women.”
Just starting these conversations – with patients, with colleagues, with family and friends – might be the most important change of all. “Even though nobody is above these issues afflicting them, this is still something that is not part of an open dialogue, and this is something that affects our own colleagues,” Dr. Mandal said. “I don’t know how many more trainees jumping out of windows it will take, or colleagues going through depression and feeling that it’s a sign of weakness to even talk about it.
“We need to create safe harbors within our own medical communities and acknowledge that we ourselves can be prone to this,” he said. “Perhaps by doing that, we will develop more empathy and become more comfortable, not just with ourselves and our colleagues but also helping these patients. People get overwhelmed and throw their hands up because it is just such a difficult issue. I don’t want people to give up, both from the medical community and our society as a whole – we can’t give up.”
A med-psych unit pilot project
Med-psych units can be a good model to take on these challenges. At Long Island Jewish Medical Center, they launched a pilot project to see how one would work in their community and summarized the results in an SHM abstract.
The hospital shares a campus with a 200-bed inpatient psych hospital, and doctors were seeing a lot of back and forth between the two institutions, said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “Patients would come into the hospital because they had an active medical issue, but because of their behavioral issues, they’d have to have continuous observation. It would not be uncommon for us to have sometimes close to 30 patients who needed 24-hour continuous observation to make sure they were not hurting themselves.” These PCAs or nurse’s assistants were doing 8-hour shifts, so each patient needed three. “The math is staggering – and with not any better outcomes.”
So the hospital created a 15-bed closed med-psych unit for medically ill patients with behavioral health disorders. They staffed it with a dedicated hospitalist, a nurse practitioner, a psychologist, and a nurse manager.
The number of patients requiring continuous observation fell to single digits. Once in their own unit, these patients caused less disruption and stress on the medical units. They had a lower length of stay compared to their previous admissions in other units, and this became one of the hospital’s highest performing units in terms of patient experience.
The biggest secret of their success, Dr. Karlin-Zysman said, is cohorting. “Instead of them going to the next open bed, wherever it may be, you get the patients all in one place geographically, with a team trained to manage those patients.” Another factor: it’s a hospitalist-run unit. “You can’t have 20 different doctors taking care of the patients; it’s one or two hospitalists running this unit.”
Care models like this can be a true win-win, and her hospital is using them more and more.
“I have a care model that’s a stroke unit; I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. “We’re creating these true teams, which I think hospitalists really like being part of. What’s that thing that makes them want to come to work every day? Things like this: running a care model, becoming specialized in something.” There are research and abstract opportunities for hospitalists on these units too, which also helps keep them engaged, she said. “I’ve used this care model and things like that to reduce burnout and keep people excited.”
The persistent mortality gap
Patients with mental illness tend to receive worse medical care than people without, studies have shown; they die an average of 25 years earlier, largely from preventable or treatable conditions such as cardiovascular disease and diabetes. The World Health Organization has called the problem “a hidden human rights emergency.”
In one in a series of articles on mental health, Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston, raises the question: Might physician attitudes toward mentally ill people contribute to this mortality gap, and if so, can we change them?
She recognizes the many obstacles physicians face in treating these patients. “The medicines we have are good but not great and can cause obesity and diabetes, which contributes to cardiovascular morbidity and mortality,” Dr. Rosenbaum said. “We have the adherence challenge for the psychiatric medications and for medications for chronic disease. It’s hard enough for anyone to take a medicine every day, and to do that if you’re homeless or you don’t have insight into the need for it, it’s really hard.”
Also, certain behaviors that are more common among people with serious mental illness – smoking, substance abuse, physical inactivity – increase their risk for chronic diseases.
These hurdles may foster a sense of helplessness among hospitalists who have just a small amount of time to spend with a patient, and attitudes may be hard to change.
“Negotiating more effectively about care refusals, more adeptly assessing capacity, and recognizing when our efforts to orchestrate care have been inadequate seem feasible,” Dr. Rosenbaum writes. “Far harder is overcoming any collective belief that what mentally ill people truly need is not something we can offer.” That’s why a truly honest examination of attitudes and biases is a necessary place to start.
She tells the story of one mentally ill patient she learned of in her research, who, after decades as the quintessential frequent flier in the ER, was living stably in the community. “No one could have known how many tries it would take to help him get there,” she writes. His doctor told her, “Let’s say 10 attempts are necessary. Someone needs to be number 2, 3 and 7. You just never know which number you are.”
Education for physicians
A course created by the National Alliance on Mental Illness addresses mental illness issues from a provider perspective.
“Although the description states that the course is intended for mental health professionals, it can be and has been used to educate and inform other healthcare professionals as well,” said Ron Honberg, JD, senior policy advisor for the National Alliance on Mental Illness. The standard course takes 15 hours; there is an abbreviated 4-hour alternative as well. More information can be found at http://www.nami.org/Find-Support/NAMI-Programs/NAMI-Provider-Education.
Sources
1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/. Accessed March 10, 2017.
2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/state-mental-health-america. Accessed March 30, 2017.
3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a Hybrid Medicine and Psychiatric Unit to Manage Medically Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http://www.shmabstracts.com/abstract/creating-a-hybrid-medicine-and-psychiatric-unit-to-manage-medically-ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017.
4. Garey J. When Doctors Discriminate. New York Times. http://www.nytimes.com/2013/08/11/opinion/sunday/when-doctors-discriminate.html. August 10, 2013. Accessed March 15, 2017.
5. Rosenbaum L. Closing the Mortality Gap – Mental Illness and Medical Care. N Engl J Med. 2016; 375:1585-1589. doi: 10.1056/NEJMms1610125.
6. Rosenbaum L. Unlearning Our Helplessness – Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016;375:1690-4. doi: 10.1056/NEJMms1610127.
The numbers tell a grim story. Nationwide, 43.7 million adult Americans experienced a mental health condition during 2016 – an increase of 1.2 million over the previous year. Mental health issues send almost 5.5 million people to emergency departments each year; nearly 60% of adults with a mental illness received no treatment at all.
If that massive – and growing – need is one side of the story, shrinking resources are the other. Mental health resources had already been diminishing for decades before the recession hit – and hit them especially hard. Between 2009 and 2012, states cut $5 billion in mental health services; during that time, at least 4,500 public psychiatric hospital beds nationwide disappeared – nearly 10% of the total supply. The bulk of those resources have never been restored.
Provider numbers also are falling. “Psychiatry is probably the top manpower shortage among all specialties,” said Joe Parks, MD, medical director of the National Council for Behavioral Health. “We have about a third the number of psychiatrists that most estimates say we need, and the number per capita is decreasing.” A significant percentage of psychiatrists – more than 50% – only accept cash, bypassing the low reimbursement rates even private insurance typically offers.
This is all evidence of our broad unwillingness, as a society, to invest in mental health, said Teresa Nguyen, LCSW, vice president of policy and programs at Mental Health America. “If we can’t reimburse people fairly for doing really important work, we’re not going to drive up the demand for more people to think about how to better serve people from a mental health perspective.”
Hospitals, of course, feel those financial disincentives too, which discourage them from investments of their own. “It’s a difficult population to manage, and it’s difficult to manage the financial realities of mental health as well,” said John McHugh, PhD, assistant professor of health policy at Columbia University, New York. “If you were a hospital administrator looking to invest your last dollar and you have the option of investing it in a new heart institute or in behavioral health service, more likely than not, you’re going to invest it in the more profitable cardiovascular service line.”
Providers of last resort
But much of the burden of caring for this population ends up falling on hospitals by default. At Denver Health, Melanie Rylander, MD, medical director of the inpatient psychiatric unit, reports seeing this manifest in three categories of patients. First, there is an influx of people coming into the emergency department with primary mental health issues.
“We’re also seeing an influx of people coming in with physical problems, and upon assessment it becomes very clear very quickly that the real issue is an underlying mental health issue,” she said. Then there are the people coming in for the same physical problems over and over – maybe decompensated heart failure or COPD exacerbations – because mental health issues are impeding their ability to take care of themselves.
Some hospitalists say they feel ill equipped to care for these patients. “We don’t have the facility or the resources many times to properly care for their psychiatric needs when they’re in the hospital. It’s not really part of an internist’s training to be familiar with a lot of the medications,” said Atashi Mandal, MD, a hospitalist and pediatrician in Los Angeles. “Sometimes they get improperly medicated because we don’t know what else to do and the patient’s behavioral issues are escalating, so it’s really a difficult position.”
It’s a dispiriting experience for a hospitalist. “It really bothers me when I am trying to care for a patient who has psychiatric needs, and I feel I’m not able to do it, and I can’t find resources, and I feel that this patient’s needs are being neglected – not because we don’t care, and not because of a lack of effort by the staff. It’s just set up to fail,” Dr. Mandal said.
Ending the silo mentality
Encouraging a more holistic view of health across health care would be an important step to begin to address the problem – after all, the mind and the body are not separate.
“We work in silos, and we really have to stop doing that because these are intertwined,” said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “A schizophrenic will become worse when they’re medically ill. That illness will be harder to treat if their psychiatric illness is active.” This is starting to happen in the outpatient setting, evidenced by the expansion of the integrated care model, where a primary care doctor is the lead physician working in combination with psychologists, psychiatrists, and social workers. Communication among providers becomes simpler, and patients don’t fall through the cracks as often while trying to navigate the system.
“How do we promote even more of that? If we make things easier for patients and increase the odds of compliance, then maybe they won’t need to go to the hospital,” Dr. Karlin-Zysman said. “Patients with behavioral health issues are just not getting the level of care and attention they need, and we have to figure it out. They’re going to be a bigger and bigger proportion of patients that we’re going to see in the hospital setting, but it doesn’t have to be dealt with in the hospital setting if it’s better treated in the outpatient setting.”
That idea of integration is also making its way into the hospital setting in various ways. In their efforts to bring the care to the patient, rather than the other way around, Dr. Karlin-Zysman’s hospital embedded two hospitalists in the neighboring inpatient psychiatric hospital; when patients need medical treatment, they can receive it without interrupting their behavioral health treatment. As a result, patients who used to end up in their emergency department don’t anymore, and their 30-day readmission rate has fallen by 50%.
But at its foundation, care integration is more of an attitude than a system; it begins with a mindset.
“We talk so much today about system reform, integrated systems, blah, blah,” said Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston. “I don’t want to make it seem like it’s not going to work, but what does it mean for the patient who is psychotic and has 10 problems, with whom you have 15 minutes? Taking good care of these patients means you have to take a deep breath and put in a lot of time and deal with all these things that have nothing to do with the health system under which you practice. There’s this ‘only so much you can do’ feeling that is a problem in itself, because there’s actually a lot we can do.”
Hospitals and communities
It’s axiomatic to say that a better approach to mental health would be based around prevention and early intervention, rather than the less crisis-oriented system we have now. Some efforts are being made in that direction, and they involve, and require, outreach outside the hospital.
“The best hospitals doing work in mental health are going beyond the hospital walls; they’re really looking at their community,” Dr. Nguyen said. “You have hospitals, like Accountable Care Organizations, who are trying to move earlier and think about mental health from a pediatric standpoint: How can we support parents and children during critical phases of brain growth? How can we provide prevention services?” Ultimately, those efforts should help lower future admission rates to EDs and hospitals.
That forward-looking approach may be necessary, but it’s also a challenge. “As a hospital administrator, I would think that you look out at the community and see this problem is not going away – in fact, it is likely going to get worse,” Dr. McHugh said. “A health system may look at themselves and say we have to take the lead on this.” The difficulty is that thinking of it in a sense of value to the community, and making the requisite investments, will have a very long period of payout; a health system that’s struggling may not be able to do it. “It’s the large [health systems] that tend to be more integrated … that are thinking about this much differently,” he said.
Still, the reality is that’s where the root of the problem lies, Dr. Rylander said – not in the hospital, but in the larger community. “In the absence of very basic needs – stable housing, food, heating – it’s really not reasonable to expect that people are going to take care of their physical needs,” she said. “It’s a much larger social issue: how to get resources so that these people can have stable places to live, they can get to and from appointments, that type of thing.”
Those needs are ongoing, of course. Many of these patients suffer from chronic conditions, meaning people will continue to need services and support, said Ron Honberg, JD, senior policy adviser for the National Alliance on Mental Illness. Often, people need services from different systems. “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on the providers of last resort, and that includes hospitals,” he said.
A collaborative effort may be needed, but hospitals can still be active participants and even leaders.
“If hospitals really want to address these problems, they need to be part of the discussions taking place in communities among the various systems and providers and advocates,” Mr. Honberg said. “Ultimately, we need to develop a better community-based system of care, and a better way of handing people off from inpatient to community-based treatment, and some accountability in terms of requiring that people get services, so they don’t get rehospitalized quickly. You’re increasingly seeing accountability now with other health conditions; we’re measuring things in Medicare like rehospitalization rates and the like. We need to be doing that with mental health treatment as well.”
What a hospitalist can do
One thing hospitalists might consider is starting that practice at their own hospitals, measuring, recording, and sharing that kind of information.
“Hospitalists should measure systematically, and in a very neutral manner, the total burden and frequency of the problem and report it consistently to management, along with their assessment that this impairs the quality of care and creates patient risk,” Dr. Parks said. That information can help hospitalists lobby for access to psychiatric personnel, be that in person or through telemedicine. “We don’t have to lay hands on you. There’s no excuse for any hospital not having a contract in place for on-demand consultation in the ER and on the floors.”
Track outcomes, too, Dr. Mandal suggests. With access to the right personnel, are you getting patients out of the ED faster? Are you having fewer negative outcomes while these patients are in the hospital, such as having to use restraints or get security involved? “Hopefully you can get some data in terms of how much money you’ve saved by decreasing the length of stays and decreasing inadvertent adverse effects because the patients weren’t receiving the proper care,” he said.
As this challenge seems likely to continue to grow, hospitalists might consider finding more training in mental health issues themselves so they are more comfortable handling these issues, Dr. Parks said. “The average mini-psych rotation from medical school is only 4 weeks,” he noted. “The ob.gyn. is at least 8 weeks and often 12 weeks, and if you don’t go into ob.gyn., you’re going to see a lot more mentally ill people through the rest of your practice, no matter what you do, than you are going to see pregnant women.”
Just starting these conversations – with patients, with colleagues, with family and friends – might be the most important change of all. “Even though nobody is above these issues afflicting them, this is still something that is not part of an open dialogue, and this is something that affects our own colleagues,” Dr. Mandal said. “I don’t know how many more trainees jumping out of windows it will take, or colleagues going through depression and feeling that it’s a sign of weakness to even talk about it.
“We need to create safe harbors within our own medical communities and acknowledge that we ourselves can be prone to this,” he said. “Perhaps by doing that, we will develop more empathy and become more comfortable, not just with ourselves and our colleagues but also helping these patients. People get overwhelmed and throw their hands up because it is just such a difficult issue. I don’t want people to give up, both from the medical community and our society as a whole – we can’t give up.”
A med-psych unit pilot project
Med-psych units can be a good model to take on these challenges. At Long Island Jewish Medical Center, they launched a pilot project to see how one would work in their community and summarized the results in an SHM abstract.
The hospital shares a campus with a 200-bed inpatient psych hospital, and doctors were seeing a lot of back and forth between the two institutions, said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “Patients would come into the hospital because they had an active medical issue, but because of their behavioral issues, they’d have to have continuous observation. It would not be uncommon for us to have sometimes close to 30 patients who needed 24-hour continuous observation to make sure they were not hurting themselves.” These PCAs or nurse’s assistants were doing 8-hour shifts, so each patient needed three. “The math is staggering – and with not any better outcomes.”
So the hospital created a 15-bed closed med-psych unit for medically ill patients with behavioral health disorders. They staffed it with a dedicated hospitalist, a nurse practitioner, a psychologist, and a nurse manager.
The number of patients requiring continuous observation fell to single digits. Once in their own unit, these patients caused less disruption and stress on the medical units. They had a lower length of stay compared to their previous admissions in other units, and this became one of the hospital’s highest performing units in terms of patient experience.
The biggest secret of their success, Dr. Karlin-Zysman said, is cohorting. “Instead of them going to the next open bed, wherever it may be, you get the patients all in one place geographically, with a team trained to manage those patients.” Another factor: it’s a hospitalist-run unit. “You can’t have 20 different doctors taking care of the patients; it’s one or two hospitalists running this unit.”
Care models like this can be a true win-win, and her hospital is using them more and more.
“I have a care model that’s a stroke unit; I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. “We’re creating these true teams, which I think hospitalists really like being part of. What’s that thing that makes them want to come to work every day? Things like this: running a care model, becoming specialized in something.” There are research and abstract opportunities for hospitalists on these units too, which also helps keep them engaged, she said. “I’ve used this care model and things like that to reduce burnout and keep people excited.”
The persistent mortality gap
Patients with mental illness tend to receive worse medical care than people without, studies have shown; they die an average of 25 years earlier, largely from preventable or treatable conditions such as cardiovascular disease and diabetes. The World Health Organization has called the problem “a hidden human rights emergency.”
In one in a series of articles on mental health, Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston, raises the question: Might physician attitudes toward mentally ill people contribute to this mortality gap, and if so, can we change them?
She recognizes the many obstacles physicians face in treating these patients. “The medicines we have are good but not great and can cause obesity and diabetes, which contributes to cardiovascular morbidity and mortality,” Dr. Rosenbaum said. “We have the adherence challenge for the psychiatric medications and for medications for chronic disease. It’s hard enough for anyone to take a medicine every day, and to do that if you’re homeless or you don’t have insight into the need for it, it’s really hard.”
Also, certain behaviors that are more common among people with serious mental illness – smoking, substance abuse, physical inactivity – increase their risk for chronic diseases.
These hurdles may foster a sense of helplessness among hospitalists who have just a small amount of time to spend with a patient, and attitudes may be hard to change.
“Negotiating more effectively about care refusals, more adeptly assessing capacity, and recognizing when our efforts to orchestrate care have been inadequate seem feasible,” Dr. Rosenbaum writes. “Far harder is overcoming any collective belief that what mentally ill people truly need is not something we can offer.” That’s why a truly honest examination of attitudes and biases is a necessary place to start.
She tells the story of one mentally ill patient she learned of in her research, who, after decades as the quintessential frequent flier in the ER, was living stably in the community. “No one could have known how many tries it would take to help him get there,” she writes. His doctor told her, “Let’s say 10 attempts are necessary. Someone needs to be number 2, 3 and 7. You just never know which number you are.”
Education for physicians
A course created by the National Alliance on Mental Illness addresses mental illness issues from a provider perspective.
“Although the description states that the course is intended for mental health professionals, it can be and has been used to educate and inform other healthcare professionals as well,” said Ron Honberg, JD, senior policy advisor for the National Alliance on Mental Illness. The standard course takes 15 hours; there is an abbreviated 4-hour alternative as well. More information can be found at http://www.nami.org/Find-Support/NAMI-Programs/NAMI-Provider-Education.
Sources
1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/. Accessed March 10, 2017.
2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/state-mental-health-america. Accessed March 30, 2017.
3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a Hybrid Medicine and Psychiatric Unit to Manage Medically Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http://www.shmabstracts.com/abstract/creating-a-hybrid-medicine-and-psychiatric-unit-to-manage-medically-ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017.
4. Garey J. When Doctors Discriminate. New York Times. http://www.nytimes.com/2013/08/11/opinion/sunday/when-doctors-discriminate.html. August 10, 2013. Accessed March 15, 2017.
5. Rosenbaum L. Closing the Mortality Gap – Mental Illness and Medical Care. N Engl J Med. 2016; 375:1585-1589. doi: 10.1056/NEJMms1610125.
6. Rosenbaum L. Unlearning Our Helplessness – Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016;375:1690-4. doi: 10.1056/NEJMms1610127.
Putting Choosing Wisely into practice
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
The project reduced mean per-person catheter days from 3.3 to 2.9, decreased catheter-associated urinary tract infection rates from 2.85 to 0.32 per 1,000 catheter days, and reduced costs by $32,245. Such results are replicable, Dr. Cho said, adding that the most important factor in this project’s success was the High Value Care committee at Mount Sinai, in New York: a team of 90 faculty members, residents, and students mobilized for undertakings like this.
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
The project reduced mean per-person catheter days from 3.3 to 2.9, decreased catheter-associated urinary tract infection rates from 2.85 to 0.32 per 1,000 catheter days, and reduced costs by $32,245. Such results are replicable, Dr. Cho said, adding that the most important factor in this project’s success was the High Value Care committee at Mount Sinai, in New York: a team of 90 faculty members, residents, and students mobilized for undertakings like this.
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
The project reduced mean per-person catheter days from 3.3 to 2.9, decreased catheter-associated urinary tract infection rates from 2.85 to 0.32 per 1,000 catheter days, and reduced costs by $32,245. Such results are replicable, Dr. Cho said, adding that the most important factor in this project’s success was the High Value Care committee at Mount Sinai, in New York: a team of 90 faculty members, residents, and students mobilized for undertakings like this.
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
Reducing harm: When doing less is enough
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
“What we’re trying to do is avoid harm,” said Daniel Wolfson, executive vice president and chief operating officer of ABIM. “That harm can be clinical, physical, psychological, and financial. That’s what we’re trying to reduce.”
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
To help communicate these messages to patients, Choosing Wisely partnered early on with Consumer Reports, and hospitalists count that partnership as another success. By producing reports, brochures, and videos that translate medical language into layman’s terms and offer patients specific advice about talking with their provider – all under the trusted Consumer Reports name – the company provides tools for physicians to make these conversations transpire more efficiently.
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s part of what makes that conversation with the patient so difficult from the provider’s side – that idea that taking away care from them can actually be better for them,” said Alexander Mainor, JD, MPH, research project coordinator at the Dartmouth Institute, which published “Physician Perceptions of Choosing Wisely and Drivers of Overuse.”2
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
“That’s the patient-centered part of this process that I think is very important and is always a challenge,” said Harry Cho, MD, FACP, director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York. “Doctors need to understand patients, too. Their thought may be, ‘I want more tests so that the doctor can make a better decision.’ Understanding where that knowledge gap is and what we need to do in terms of education and reaching out to patients and making the decision together, I think, will be very helpful.”
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
Perhaps these additional conversations will start to happen as value becomes a more defined career path in hospital medicine and as the ideas behind Choosing Wisely continue to move to the forefront.
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
“What we’re trying to do is avoid harm,” said Daniel Wolfson, executive vice president and chief operating officer of ABIM. “That harm can be clinical, physical, psychological, and financial. That’s what we’re trying to reduce.”
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
To help communicate these messages to patients, Choosing Wisely partnered early on with Consumer Reports, and hospitalists count that partnership as another success. By producing reports, brochures, and videos that translate medical language into layman’s terms and offer patients specific advice about talking with their provider – all under the trusted Consumer Reports name – the company provides tools for physicians to make these conversations transpire more efficiently.
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s part of what makes that conversation with the patient so difficult from the provider’s side – that idea that taking away care from them can actually be better for them,” said Alexander Mainor, JD, MPH, research project coordinator at the Dartmouth Institute, which published “Physician Perceptions of Choosing Wisely and Drivers of Overuse.”2
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
“That’s the patient-centered part of this process that I think is very important and is always a challenge,” said Harry Cho, MD, FACP, director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York. “Doctors need to understand patients, too. Their thought may be, ‘I want more tests so that the doctor can make a better decision.’ Understanding where that knowledge gap is and what we need to do in terms of education and reaching out to patients and making the decision together, I think, will be very helpful.”
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
Perhaps these additional conversations will start to happen as value becomes a more defined career path in hospital medicine and as the ideas behind Choosing Wisely continue to move to the forefront.
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
“What we’re trying to do is avoid harm,” said Daniel Wolfson, executive vice president and chief operating officer of ABIM. “That harm can be clinical, physical, psychological, and financial. That’s what we’re trying to reduce.”
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
To help communicate these messages to patients, Choosing Wisely partnered early on with Consumer Reports, and hospitalists count that partnership as another success. By producing reports, brochures, and videos that translate medical language into layman’s terms and offer patients specific advice about talking with their provider – all under the trusted Consumer Reports name – the company provides tools for physicians to make these conversations transpire more efficiently.
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s part of what makes that conversation with the patient so difficult from the provider’s side – that idea that taking away care from them can actually be better for them,” said Alexander Mainor, JD, MPH, research project coordinator at the Dartmouth Institute, which published “Physician Perceptions of Choosing Wisely and Drivers of Overuse.”2
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
“That’s the patient-centered part of this process that I think is very important and is always a challenge,” said Harry Cho, MD, FACP, director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York. “Doctors need to understand patients, too. Their thought may be, ‘I want more tests so that the doctor can make a better decision.’ Understanding where that knowledge gap is and what we need to do in terms of education and reaching out to patients and making the decision together, I think, will be very helpful.”
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
Perhaps these additional conversations will start to happen as value becomes a more defined career path in hospital medicine and as the ideas behind Choosing Wisely continue to move to the forefront.
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Applying Choosing Wisely principles to telemetry and catheter use
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
Improving transitions for elderly patients
Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.
“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.”
To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.
The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”
Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.
Reference
Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.
Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.
“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.”
To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.
The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”
Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.
Reference
Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.
Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.
“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.”
To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.
The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”
Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.
Reference
Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.
Quick Byte: Telemental health visits on the rise
Telemental health visits are on the rise.
In 2014, there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively.
Reference
Mehrotra A, Huskamp HA, Souza J, et al. Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states. Health Aff. 2017 May 1;36(5):909-17. Accessed May 24, 2017.
Telemental health visits are on the rise.
In 2014, there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively.
Reference
Mehrotra A, Huskamp HA, Souza J, et al. Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states. Health Aff. 2017 May 1;36(5):909-17. Accessed May 24, 2017.
Telemental health visits are on the rise.
In 2014, there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively.
Reference
Mehrotra A, Huskamp HA, Souza J, et al. Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states. Health Aff. 2017 May 1;36(5):909-17. Accessed May 24, 2017.
Walking the halls of power
Hospital medicine may be a young specialty, but it is already playing a significant role in both front-line patient care and, increasingly, in shaping public policy. Case in point: Two hospitalists serving currently in key roles in the federal government, and two former top civil servants, each of whom are examples of the growing influence of the hospitalist perspective.
“The hospitalist viewpoint of the health care system is a unique one, and it lends itself very well to the challenges of our current delivery system reform. We’re reforming the health care system to deliver care more cost effectively,” said Ron Greeno, MD, FCCP, MHM, SHM president and chair of the SHM Public Policy committee. “Hospitalists are trained to do that – they go to work every day to do that.”
Leading the FDA
One of the three is Scott Gottlieb, MD, Commissioner of the FDA, formerly a resident fellow at the American Enterprise Institute (AEI), where he studied health care reform, the Centers for Medicare and Medicaid Services, and the FDA.
“He’s the perfect person for that job and is looking to shake things up,” Dr. Greeno said. “There are a lot of things that can improve in terms of how drugs get to market, including lower cost generic drugs.” That’s an issue Dr. Gottlieb has been championing for years, and his understanding of the issue also makes him well prepared to take this position now, Dr. Greeno said.
“Dr. Gottlieb’s nomination comes at a momentous time for the agency, which Mr. Trump has promised to significantly remake,” the New York Times wrote on March 29, prior to his confirmation. “The next commissioner will be charged with putting into practice a far-reaching law, passed in December, aimed at bringing drugs to market more quickly.”
In addition to his work at the AEI, Dr. Gottlieb served on SHM’s Public Policy committee. He was a clinical assistant professor at New York University School of Medicine and advised the U.S. Department of Health and Human Services as a member of the Federal Health IT Policy committee.
Steering national quality programs
Kate Goodrich’s preparation for her government role included experience with several sides of the health care system: Dr. Goodrich, MD, MHS, was the director of the Division of Hospital Medicine at George Washington University Hospital, one of the first hospitalist programs in the Washington area. She worked at an inpatient rehab facility and has practiced in ambulatory care.
“That’s allowed me to see a variety of different facets of the health care system writ large,” Dr. Goodrich said. “Understanding how systems work, I think, is really key to making policy decisions.”
Now, as chief medical officer of CMS and director of the Center for Clinical Standards and Quality (CCSQ), she’s helping drive those policy decisions, overseeing multiple quality measurement and value-based purchasing programs and health and safety standards for hospitals.
Dr. Goodrich still makes rounds at George Washington Hospital on weekends. “It allows me to have a sort of in-your-bones understanding of the challenges of frontline providers,” she said. “I’m able to understand the clinician point of view in our policy decisions.” She’s also able to see first-hand the effects of those policy decisions on clinicians, patients, and health care systems.
As physician leaders within their organizations, hospitalists fit naturally into other leadership positions, she said. “Hospitalists often take leadership roles around quality of care and efficiency and flow and those sorts of thing,” Dr. Goodrich said. “I think it is a very natural progression for hospitalists to get interested in health care and medicine from that viewpoint, which then might allow them to make a leap into another type of field.”
An innovator at CMS
Until very recently, pediatric hospitalist Patrick Conway, MD, FAAP, MHM, served as deputy administrator for Innovation and Quality at the Centers for Medicare & Medicaid Services and director of the Center for Medicare and Medicaid Innovation. On Oct. 1, he took on a new challenge, becoming president and CEO of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
While at CMS, Dr. Conway was responsible for leading for all policy coordination and execution across Medicare, Medicaid, and the Children’s Health Insurance Program. He also headed up health care delivery system transformation at CMS, and in his CMMI role, he was responsible for launching new payment and service delivery models.
Dr. Conway was selected as a Master of Hospital Medicine by SHM, and received the HHS Secretary’s Award for Distinguished Service, the Secretary’s highest distinction for excellence. The Patient Safety Movement Foundation gave him their Humanitarian Award, and in February 2017, he received the AMA’s Dr. Nathan Davis Award for Outstanding Government Service. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014.
Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
Improving the country’s health
Obesity, tobacco-related disease, mental illness, and addiction are some of the issues Vivek H. Murthy, MD, MBA, targeted while serving as the 19th U.S. Surgeon General. He was appointed to the position by President Obama in 2014, and was relieved of his duties by President Trump in April 2017.
Dr. Murthy, a hospitalist at Brigham and Women’s Hospital in Boston before he was confirmed as Surgeon General (at 37, the youngest one ever), also has an extensive record of health care-related entrepreneurship and outreach. He cofounded VISIONS, an HIV/AIDS education program in India and the United States, and the Swasthya project, a community health partnership in rural India. Dr. Murthy founded Doctors for Obama (later Doctors for America), a nonprofit organization of physicians and medical students dedicated to creating equal access to affordable health care nationwide.
Dr. Murthy has said that addiction should be seen as a chronic illness, not a character flaw, and last year sent a letter to 2.3 million health care providers nationwide, encouraging them to join a national effort to reform prescribing practices.
According to Dr. Greeno, each of these hospitalists illuminates new paths for others in the field. “I think for young people who are trying to identify what career path they want to pursue, this is something that can’t be anything but good for our specialty – and good for the health system,” he said. “Hospitalists have the perfect clinical background and mindset to help our health care system get to where it needs to go. It’s a huge challenge. It’s going to be a ton of work, and the stakes are very, very high.”
Reference
1. Thomas K. F.D.A. Nominee, Paid Millions by Industry, Says He’ll Recuse Himself if Needed. New York Times. March 29, 2017. https://www.nytimes.com/2017/03/29/health/fda-nominee-scott-gottlieb-recuse-conflicts.html?_r=0. Accessed March 31, 2017.
Hospital medicine may be a young specialty, but it is already playing a significant role in both front-line patient care and, increasingly, in shaping public policy. Case in point: Two hospitalists serving currently in key roles in the federal government, and two former top civil servants, each of whom are examples of the growing influence of the hospitalist perspective.
“The hospitalist viewpoint of the health care system is a unique one, and it lends itself very well to the challenges of our current delivery system reform. We’re reforming the health care system to deliver care more cost effectively,” said Ron Greeno, MD, FCCP, MHM, SHM president and chair of the SHM Public Policy committee. “Hospitalists are trained to do that – they go to work every day to do that.”
Leading the FDA
One of the three is Scott Gottlieb, MD, Commissioner of the FDA, formerly a resident fellow at the American Enterprise Institute (AEI), where he studied health care reform, the Centers for Medicare and Medicaid Services, and the FDA.
“He’s the perfect person for that job and is looking to shake things up,” Dr. Greeno said. “There are a lot of things that can improve in terms of how drugs get to market, including lower cost generic drugs.” That’s an issue Dr. Gottlieb has been championing for years, and his understanding of the issue also makes him well prepared to take this position now, Dr. Greeno said.
“Dr. Gottlieb’s nomination comes at a momentous time for the agency, which Mr. Trump has promised to significantly remake,” the New York Times wrote on March 29, prior to his confirmation. “The next commissioner will be charged with putting into practice a far-reaching law, passed in December, aimed at bringing drugs to market more quickly.”
In addition to his work at the AEI, Dr. Gottlieb served on SHM’s Public Policy committee. He was a clinical assistant professor at New York University School of Medicine and advised the U.S. Department of Health and Human Services as a member of the Federal Health IT Policy committee.
Steering national quality programs
Kate Goodrich’s preparation for her government role included experience with several sides of the health care system: Dr. Goodrich, MD, MHS, was the director of the Division of Hospital Medicine at George Washington University Hospital, one of the first hospitalist programs in the Washington area. She worked at an inpatient rehab facility and has practiced in ambulatory care.
“That’s allowed me to see a variety of different facets of the health care system writ large,” Dr. Goodrich said. “Understanding how systems work, I think, is really key to making policy decisions.”
Now, as chief medical officer of CMS and director of the Center for Clinical Standards and Quality (CCSQ), she’s helping drive those policy decisions, overseeing multiple quality measurement and value-based purchasing programs and health and safety standards for hospitals.
Dr. Goodrich still makes rounds at George Washington Hospital on weekends. “It allows me to have a sort of in-your-bones understanding of the challenges of frontline providers,” she said. “I’m able to understand the clinician point of view in our policy decisions.” She’s also able to see first-hand the effects of those policy decisions on clinicians, patients, and health care systems.
As physician leaders within their organizations, hospitalists fit naturally into other leadership positions, she said. “Hospitalists often take leadership roles around quality of care and efficiency and flow and those sorts of thing,” Dr. Goodrich said. “I think it is a very natural progression for hospitalists to get interested in health care and medicine from that viewpoint, which then might allow them to make a leap into another type of field.”
An innovator at CMS
Until very recently, pediatric hospitalist Patrick Conway, MD, FAAP, MHM, served as deputy administrator for Innovation and Quality at the Centers for Medicare & Medicaid Services and director of the Center for Medicare and Medicaid Innovation. On Oct. 1, he took on a new challenge, becoming president and CEO of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
While at CMS, Dr. Conway was responsible for leading for all policy coordination and execution across Medicare, Medicaid, and the Children’s Health Insurance Program. He also headed up health care delivery system transformation at CMS, and in his CMMI role, he was responsible for launching new payment and service delivery models.
Dr. Conway was selected as a Master of Hospital Medicine by SHM, and received the HHS Secretary’s Award for Distinguished Service, the Secretary’s highest distinction for excellence. The Patient Safety Movement Foundation gave him their Humanitarian Award, and in February 2017, he received the AMA’s Dr. Nathan Davis Award for Outstanding Government Service. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014.
Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
Improving the country’s health
Obesity, tobacco-related disease, mental illness, and addiction are some of the issues Vivek H. Murthy, MD, MBA, targeted while serving as the 19th U.S. Surgeon General. He was appointed to the position by President Obama in 2014, and was relieved of his duties by President Trump in April 2017.
Dr. Murthy, a hospitalist at Brigham and Women’s Hospital in Boston before he was confirmed as Surgeon General (at 37, the youngest one ever), also has an extensive record of health care-related entrepreneurship and outreach. He cofounded VISIONS, an HIV/AIDS education program in India and the United States, and the Swasthya project, a community health partnership in rural India. Dr. Murthy founded Doctors for Obama (later Doctors for America), a nonprofit organization of physicians and medical students dedicated to creating equal access to affordable health care nationwide.
Dr. Murthy has said that addiction should be seen as a chronic illness, not a character flaw, and last year sent a letter to 2.3 million health care providers nationwide, encouraging them to join a national effort to reform prescribing practices.
According to Dr. Greeno, each of these hospitalists illuminates new paths for others in the field. “I think for young people who are trying to identify what career path they want to pursue, this is something that can’t be anything but good for our specialty – and good for the health system,” he said. “Hospitalists have the perfect clinical background and mindset to help our health care system get to where it needs to go. It’s a huge challenge. It’s going to be a ton of work, and the stakes are very, very high.”
Reference
1. Thomas K. F.D.A. Nominee, Paid Millions by Industry, Says He’ll Recuse Himself if Needed. New York Times. March 29, 2017. https://www.nytimes.com/2017/03/29/health/fda-nominee-scott-gottlieb-recuse-conflicts.html?_r=0. Accessed March 31, 2017.
Hospital medicine may be a young specialty, but it is already playing a significant role in both front-line patient care and, increasingly, in shaping public policy. Case in point: Two hospitalists serving currently in key roles in the federal government, and two former top civil servants, each of whom are examples of the growing influence of the hospitalist perspective.
“The hospitalist viewpoint of the health care system is a unique one, and it lends itself very well to the challenges of our current delivery system reform. We’re reforming the health care system to deliver care more cost effectively,” said Ron Greeno, MD, FCCP, MHM, SHM president and chair of the SHM Public Policy committee. “Hospitalists are trained to do that – they go to work every day to do that.”
Leading the FDA
One of the three is Scott Gottlieb, MD, Commissioner of the FDA, formerly a resident fellow at the American Enterprise Institute (AEI), where he studied health care reform, the Centers for Medicare and Medicaid Services, and the FDA.
“He’s the perfect person for that job and is looking to shake things up,” Dr. Greeno said. “There are a lot of things that can improve in terms of how drugs get to market, including lower cost generic drugs.” That’s an issue Dr. Gottlieb has been championing for years, and his understanding of the issue also makes him well prepared to take this position now, Dr. Greeno said.
“Dr. Gottlieb’s nomination comes at a momentous time for the agency, which Mr. Trump has promised to significantly remake,” the New York Times wrote on March 29, prior to his confirmation. “The next commissioner will be charged with putting into practice a far-reaching law, passed in December, aimed at bringing drugs to market more quickly.”
In addition to his work at the AEI, Dr. Gottlieb served on SHM’s Public Policy committee. He was a clinical assistant professor at New York University School of Medicine and advised the U.S. Department of Health and Human Services as a member of the Federal Health IT Policy committee.
Steering national quality programs
Kate Goodrich’s preparation for her government role included experience with several sides of the health care system: Dr. Goodrich, MD, MHS, was the director of the Division of Hospital Medicine at George Washington University Hospital, one of the first hospitalist programs in the Washington area. She worked at an inpatient rehab facility and has practiced in ambulatory care.
“That’s allowed me to see a variety of different facets of the health care system writ large,” Dr. Goodrich said. “Understanding how systems work, I think, is really key to making policy decisions.”
Now, as chief medical officer of CMS and director of the Center for Clinical Standards and Quality (CCSQ), she’s helping drive those policy decisions, overseeing multiple quality measurement and value-based purchasing programs and health and safety standards for hospitals.
Dr. Goodrich still makes rounds at George Washington Hospital on weekends. “It allows me to have a sort of in-your-bones understanding of the challenges of frontline providers,” she said. “I’m able to understand the clinician point of view in our policy decisions.” She’s also able to see first-hand the effects of those policy decisions on clinicians, patients, and health care systems.
As physician leaders within their organizations, hospitalists fit naturally into other leadership positions, she said. “Hospitalists often take leadership roles around quality of care and efficiency and flow and those sorts of thing,” Dr. Goodrich said. “I think it is a very natural progression for hospitalists to get interested in health care and medicine from that viewpoint, which then might allow them to make a leap into another type of field.”
An innovator at CMS
Until very recently, pediatric hospitalist Patrick Conway, MD, FAAP, MHM, served as deputy administrator for Innovation and Quality at the Centers for Medicare & Medicaid Services and director of the Center for Medicare and Medicaid Innovation. On Oct. 1, he took on a new challenge, becoming president and CEO of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
While at CMS, Dr. Conway was responsible for leading for all policy coordination and execution across Medicare, Medicaid, and the Children’s Health Insurance Program. He also headed up health care delivery system transformation at CMS, and in his CMMI role, he was responsible for launching new payment and service delivery models.
Dr. Conway was selected as a Master of Hospital Medicine by SHM, and received the HHS Secretary’s Award for Distinguished Service, the Secretary’s highest distinction for excellence. The Patient Safety Movement Foundation gave him their Humanitarian Award, and in February 2017, he received the AMA’s Dr. Nathan Davis Award for Outstanding Government Service. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014.
Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
Improving the country’s health
Obesity, tobacco-related disease, mental illness, and addiction are some of the issues Vivek H. Murthy, MD, MBA, targeted while serving as the 19th U.S. Surgeon General. He was appointed to the position by President Obama in 2014, and was relieved of his duties by President Trump in April 2017.
Dr. Murthy, a hospitalist at Brigham and Women’s Hospital in Boston before he was confirmed as Surgeon General (at 37, the youngest one ever), also has an extensive record of health care-related entrepreneurship and outreach. He cofounded VISIONS, an HIV/AIDS education program in India and the United States, and the Swasthya project, a community health partnership in rural India. Dr. Murthy founded Doctors for Obama (later Doctors for America), a nonprofit organization of physicians and medical students dedicated to creating equal access to affordable health care nationwide.
Dr. Murthy has said that addiction should be seen as a chronic illness, not a character flaw, and last year sent a letter to 2.3 million health care providers nationwide, encouraging them to join a national effort to reform prescribing practices.
According to Dr. Greeno, each of these hospitalists illuminates new paths for others in the field. “I think for young people who are trying to identify what career path they want to pursue, this is something that can’t be anything but good for our specialty – and good for the health system,” he said. “Hospitalists have the perfect clinical background and mindset to help our health care system get to where it needs to go. It’s a huge challenge. It’s going to be a ton of work, and the stakes are very, very high.”
Reference
1. Thomas K. F.D.A. Nominee, Paid Millions by Industry, Says He’ll Recuse Himself if Needed. New York Times. March 29, 2017. https://www.nytimes.com/2017/03/29/health/fda-nominee-scott-gottlieb-recuse-conflicts.html?_r=0. Accessed March 31, 2017.
Innovations: Quality, patient safety, and technology initiatives
Measuring hospital-acquired infection in a new way
Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.
These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.
The researchers piloted an infection composite score (ICS) in 82 hospitals under a single health system. The ICS is a combined score for central line–associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. The researchers calculated individual facility ICS scores and compared them with system scores for baseline and performance.
This gives hospitals a more current picture of how they’re doing, compared with the SIR, said Mohamad G. Fakih, MD, MPH, of Ascension Health, Grosse Pointe Woods, Mich., lead author of the study. “The SIR is a ratio based on a baseline that’s usually a few years prior; it’s not the year directly before. So, when we published this paper, some of the infections had a baseline of 2006 through 2008 for the central line infections.”
Another difference is that the ICS gives the six infections the same weight, rather than combining them. “So, if you add them up together and then you divide by six, you get a score that tells you how you’re doing for infection, compared [with] the whole system. If they have a problem that’s related to many infections, then you know the culture of infection prevention in that hospital is much worse. It’s not just one product. There’s something much more worrisome for that hospital.”
This simple score can be adjusted according to a particular hospital’s needs. “Let’s say you want to focus on additional infections that are publicly reported. You can add them to that score,” Dr. Fakih says. “And you can change the weight in a way depending on what you want to focus on, or, if you want to focus on something more than others, you can increase the weight.”
References
1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.
2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.
Hospitalists lead in palliative care
According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.
“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”
The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.
“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
Reference
1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.
Improving outcomes for children with chronic conditions
Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.
The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.
Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.
Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
Reference
1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.
FDA approves two new antibiotic tests
Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.
The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.
The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.
The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
Quick byte
About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”
Reference
1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.
Measuring hospital-acquired infection in a new way
Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.
These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.
The researchers piloted an infection composite score (ICS) in 82 hospitals under a single health system. The ICS is a combined score for central line–associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. The researchers calculated individual facility ICS scores and compared them with system scores for baseline and performance.
This gives hospitals a more current picture of how they’re doing, compared with the SIR, said Mohamad G. Fakih, MD, MPH, of Ascension Health, Grosse Pointe Woods, Mich., lead author of the study. “The SIR is a ratio based on a baseline that’s usually a few years prior; it’s not the year directly before. So, when we published this paper, some of the infections had a baseline of 2006 through 2008 for the central line infections.”
Another difference is that the ICS gives the six infections the same weight, rather than combining them. “So, if you add them up together and then you divide by six, you get a score that tells you how you’re doing for infection, compared [with] the whole system. If they have a problem that’s related to many infections, then you know the culture of infection prevention in that hospital is much worse. It’s not just one product. There’s something much more worrisome for that hospital.”
This simple score can be adjusted according to a particular hospital’s needs. “Let’s say you want to focus on additional infections that are publicly reported. You can add them to that score,” Dr. Fakih says. “And you can change the weight in a way depending on what you want to focus on, or, if you want to focus on something more than others, you can increase the weight.”
References
1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.
2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.
Hospitalists lead in palliative care
According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.
“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”
The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.
“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
Reference
1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.
Improving outcomes for children with chronic conditions
Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.
The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.
Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.
Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
Reference
1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.
FDA approves two new antibiotic tests
Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.
The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.
The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.
The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
Quick byte
About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”
Reference
1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.
Measuring hospital-acquired infection in a new way
Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.
These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.
The researchers piloted an infection composite score (ICS) in 82 hospitals under a single health system. The ICS is a combined score for central line–associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. The researchers calculated individual facility ICS scores and compared them with system scores for baseline and performance.
This gives hospitals a more current picture of how they’re doing, compared with the SIR, said Mohamad G. Fakih, MD, MPH, of Ascension Health, Grosse Pointe Woods, Mich., lead author of the study. “The SIR is a ratio based on a baseline that’s usually a few years prior; it’s not the year directly before. So, when we published this paper, some of the infections had a baseline of 2006 through 2008 for the central line infections.”
Another difference is that the ICS gives the six infections the same weight, rather than combining them. “So, if you add them up together and then you divide by six, you get a score that tells you how you’re doing for infection, compared [with] the whole system. If they have a problem that’s related to many infections, then you know the culture of infection prevention in that hospital is much worse. It’s not just one product. There’s something much more worrisome for that hospital.”
This simple score can be adjusted according to a particular hospital’s needs. “Let’s say you want to focus on additional infections that are publicly reported. You can add them to that score,” Dr. Fakih says. “And you can change the weight in a way depending on what you want to focus on, or, if you want to focus on something more than others, you can increase the weight.”
References
1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.
2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.
Hospitalists lead in palliative care
According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.
“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”
The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.
“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
Reference
1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.
Improving outcomes for children with chronic conditions
Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.
The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.
Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.
Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
Reference
1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.
FDA approves two new antibiotic tests
Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.
The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.
The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.
The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
Quick byte
About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”
Reference
1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.