Quality

David Lawrence, MD, retired head of the Kaiser Foundation health plan, says in a recent Information Week article that it will be “nearly impossible” to achieve the goals of healthcare integration without the connectivity of a well-designed health IT system.⁴ Dr. Lawrence was a member of a committee that authored the recent report Order from Chaos: Accelerating Care Integration for the Lucian Leape Institute at the National Patient Care Safety Foundation. Failures of coordination most often happen during the crucial information transfers that happen during care transitions, but there has not been enough attention to how important information technology could be to these transfers, Dr. Lawrence told the magazine. “It’s the really complex stuff where this becomes particularly critical,” he said.

The federal Office of Inspector General (OIG) took the Centers for Medicare & Medicaid Services (CMS) to task in a November report for not having adequate oversight or safeguards for its EHR meaningful-use program.⁵ As a result, OIG described Medicare as “vulnerable” to fraud and abuse of incentive payments made to hospitals and health professionals, according to OIG. OIG recommends that CMS request and review supporting documentation for selected providers and issue guidance with specific examples of appropriate documentation. As of September 2012, CMS had paid out $4 billion in meaningful-use incentives to 1,400 hospitals and 82,000 professionals.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

David Lawrence, MD, retired head of the Kaiser Foundation health plan, says in a recent Information Week article that it will be “nearly impossible” to achieve the goals of healthcare integration without the connectivity of a well-designed health IT system.⁴ Dr. Lawrence was a member of a committee that authored the recent report Order from Chaos: Accelerating Care Integration for the Lucian Leape Institute at the National Patient Care Safety Foundation. Failures of coordination most often happen during the crucial information transfers that happen during care transitions, but there has not been enough attention to how important information technology could be to these transfers, Dr. Lawrence told the magazine. “It’s the really complex stuff where this becomes particularly critical,” he said.

The federal Office of Inspector General (OIG) took the Centers for Medicare & Medicaid Services (CMS) to task in a November report for not having adequate oversight or safeguards for its EHR meaningful-use program.⁵ As a result, OIG described Medicare as “vulnerable” to fraud and abuse of incentive payments made to hospitals and health professionals, according to OIG. OIG recommends that CMS request and review supporting documentation for selected providers and issue guidance with specific examples of appropriate documentation. As of September 2012, CMS had paid out $4 billion in meaningful-use incentives to 1,400 hospitals and 82,000 professionals.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

David Lawrence, MD, retired head of the Kaiser Foundation health plan, says in a recent Information Week article that it will be “nearly impossible” to achieve the goals of healthcare integration without the connectivity of a well-designed health IT system.⁴ Dr. Lawrence was a member of a committee that authored the recent report Order from Chaos: Accelerating Care Integration for the Lucian Leape Institute at the National Patient Care Safety Foundation. Failures of coordination most often happen during the crucial information transfers that happen during care transitions, but there has not been enough attention to how important information technology could be to these transfers, Dr. Lawrence told the magazine. “It’s the really complex stuff where this becomes particularly critical,” he said.

The federal Office of Inspector General (OIG) took the Centers for Medicare & Medicaid Services (CMS) to task in a November report for not having adequate oversight or safeguards for its EHR meaningful-use program.⁵ As a result, OIG described Medicare as “vulnerable” to fraud and abuse of incentive payments made to hospitals and health professionals, according to OIG. OIG recommends that CMS request and review supporting documentation for selected providers and issue guidance with specific examples of appropriate documentation. As of September 2012, CMS had paid out $4 billion in meaningful-use incentives to 1,400 hospitals and 82,000 professionals.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Click here to listen to Scott Strassels, PhD, PharmD, BCPS, an assistant professor in the College of Pharmacy at the University of Texas at Austin and a board member of the American Pain Society, discuss the risks and rewards of opioid therapies, and why continuing education is important for all clinicians.

Click here to listen to Scott Strassels, PhD, PharmD, BCPS, an assistant professor in the College of Pharmacy at the University of Texas at Austin and a board member of the American Pain Society, discuss the risks and rewards of opioid therapies, and why continuing education is important for all clinicians.

Click here to listen to Scott Strassels, PhD, PharmD, BCPS, an assistant professor in the College of Pharmacy at the University of Texas at Austin and a board member of the American Pain Society, discuss the risks and rewards of opioid therapies, and why continuing education is important for all clinicians.

Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS 1500s. The form is distinguished by its red ink.

Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS 1500s. The form is distinguished by its red ink.

Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS 1500s. The form is distinguished by its red ink.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Richard Quinn is a freelance writer in New Jersey.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Richard Quinn is a freelance writer in New Jersey.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Richard Quinn is a freelance writer in New Jersey.

New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much

When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.

As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.

Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.

Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.

“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”

But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.

“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.

Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.

“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.

Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.

Care and Discharge

Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.

“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.

“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”

Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.

Who Ends up Hospitalized?

The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.

“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.

Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.

“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”

If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”

“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.

But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.

“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.

QI Initiatives

What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”

There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.

“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”

Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.

It might be “more of a theoretical problem than one in reality,” he explains, “simply because we have not found the need to reverse oral anticoagulants very often given their short half-lives.”

The new agents, all the experts agree, will require hospitalists to stay on their toes.

“There are so many different facets in each case, whether it’s the age or the renal function or whether there’s a fall risk and what their compliance is, what their funding is, what the exact indication is,” Dr. Jenkins says. “Keeping up with those things is actually quite challenging.”

His main resources are the American College of Chest Physicians’ guidelines on anticoagulants, his center’s own protocols, and the primary literature for the main trials (see “Additional Reading,” right). He also looks to the inpatient pharmacist for guidance.

Dr. Shah says it is important to be aware of the patient-inclusion criteria, study design, and outcomes measured for each agent through their trials.

“There is a lot of information out there, and there are very subtle aspects of some of these trials and you’ve got to really understand: Does it apply to the patient that is front of me?” he said. “There’s a lot to know, there’s no doubt about it.”

Thomas R. Collins is a freelance writer in South Florida.

New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much

When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.

As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.

Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.

Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.

“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”

But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.

“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.

Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.

“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.

Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.

Care and Discharge

Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.

“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.

“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”

Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.

Who Ends up Hospitalized?

The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.

“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.

Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.

“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”

If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”

“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.

But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.

“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.

QI Initiatives

What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”

There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.

“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”

Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.

It might be “more of a theoretical problem than one in reality,” he explains, “simply because we have not found the need to reverse oral anticoagulants very often given their short half-lives.”

The new agents, all the experts agree, will require hospitalists to stay on their toes.

“There are so many different facets in each case, whether it’s the age or the renal function or whether there’s a fall risk and what their compliance is, what their funding is, what the exact indication is,” Dr. Jenkins says. “Keeping up with those things is actually quite challenging.”

His main resources are the American College of Chest Physicians’ guidelines on anticoagulants, his center’s own protocols, and the primary literature for the main trials (see “Additional Reading,” right). He also looks to the inpatient pharmacist for guidance.

Dr. Shah says it is important to be aware of the patient-inclusion criteria, study design, and outcomes measured for each agent through their trials.

“There is a lot of information out there, and there are very subtle aspects of some of these trials and you’ve got to really understand: Does it apply to the patient that is front of me?” he said. “There’s a lot to know, there’s no doubt about it.”

Thomas R. Collins is a freelance writer in South Florida.

New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much

When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.

As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.

Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.

Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.

“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”

But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.

“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.

Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.

“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.

Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.

Care and Discharge

Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.

“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.

“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”

Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.

Who Ends up Hospitalized?

The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.

“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.

Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.

“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”

If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”

“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.

But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.

“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.

QI Initiatives

What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”

There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.

“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”

Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.

It might be “more of a theoretical problem than one in reality,” he explains, “simply because we have not found the need to reverse oral anticoagulants very often given their short half-lives.”

The new agents, all the experts agree, will require hospitalists to stay on their toes.

“There are so many different facets in each case, whether it’s the age or the renal function or whether there’s a fall risk and what their compliance is, what their funding is, what the exact indication is,” Dr. Jenkins says. “Keeping up with those things is actually quite challenging.”

His main resources are the American College of Chest Physicians’ guidelines on anticoagulants, his center’s own protocols, and the primary literature for the main trials (see “Additional Reading,” right). He also looks to the inpatient pharmacist for guidance.

Dr. Shah says it is important to be aware of the patient-inclusion criteria, study design, and outcomes measured for each agent through their trials.

“There is a lot of information out there, and there are very subtle aspects of some of these trials and you’ve got to really understand: Does it apply to the patient that is front of me?” he said. “There’s a lot to know, there’s no doubt about it.”

Thomas R. Collins is a freelance writer in South Florida.

In November 2012, the Center for Medicare & Medicaid Services (CMS) finalized its 2013 physician fee schedule with two new transitional-care-management (TCM) codes, 99495 and 99496. These codes provide reimbursement for transitional-care services to patients for 30 days after hospital discharge. CMS estimates that two-thirds of the 10 million Medicare patients discharged annually from hospitals will have TCM services provided by an outpatient doctor. Why might hospitalists be interested in these outpatient codes? Read on.

As a post-discharge provider in a primary-care-based discharge clinic, I can say the new Medicare transitional codes read like our job description. Because I’ve worked in a post-discharge clinic for the past three years, I have learned that post-discharge care requires time and resource allocation beyond routine outpatient care. Because of the unique population we see, on average we bill at a higher level than the rest of the practice. Yet we, like all outpatient providers, remain constrained by the existing billing structure, which is intimately connected to physician face-to-face visits.

Here’s an illustration of a typical afternoon in the post-discharge clinic: A schizophrenic patient presents with renal failure, hypoglycemia, and confusion. Her home visiting nurse (VNA) administers her medications; the patient cannot tell you any of them. While you are calling the VNA to clarify her medications, trying to identify her healthcare proxy, and stopping her ACE inhibitor because her potassium is 5.6, the next patient arrives. She has end-stage liver disease and was recently in the hospital for liver failure, and now has worsening recurrent ascites. After clinic, you call interventional radiology to coordinate a therapeutic paracentesis and change diuretic doses after her labs return. Two weeks later, you arrange a repeat paracentesis, and subsequently a transition to comfort care in a hospice house. For this work, right now, you can at most bill a high-complexity office visit (99215), and the rest of the care coordination—by you, your nurse, or your administrative staff—is not compensated.

How Do the New Codes Work?

CMS created the new TCM codes to begin to change the outpatient fee schedule to emphasize primary care and care coordination for beneficiaries, particularly in the post-hospitalization period. The new TCM codes are a first step toward reimbursement for non-face-to-face activities, which are increasingly important in the evolving healthcare system.

The investment is estimated at more than $1 billion in 2013. The new codes are available to physicians, physician assistants, nurse practitioners, and other advanced-practice nurses only once within the 30 days after hospital discharge. During the 30 days after discharge, the two codes, 99495 and 99496, require a single face-to-face visit within seven days of discharge for the highest-risk patients and within 14 days of discharge for moderate-risk patients. The face-to-face visit is not billed separately. The codes also mandate telephone communication with the patient or caregiver within two business days of hospital discharge; the medical decision-making must be of either moderate or high complexity.

The average reimbursement for the codes will be $132.96 for 99495 and $231.11 for 99496, reflecting a higher wRVU than either hospital discharge day management or high-acuity outpatient visits. The code is billed at the end of the 30 days. The TCM code cannot be billed a second time if a patient is readmitted within the 30 days. Other E/M codes can be billed during the same time period for additional visits as necessary.

What’s the Impact on Hospitalists?

The new codes affect hospitalists in two ways. First, the hospitalists in the growing group of “transitionalists,” many of whom practice in outpatient clinics seeing patients after discharge, will be able to use these codes. As the codes require no pre-existing relationship with the patient, non-primary-care providers will be able to bill these codes, assuming that they fulfill the designated requirements. This concession enables hospitalists to fill a vital role for those patients who have inadequate access to immediate primary care post-hospitalization. It also provides a necessary bridge to appropriate primary care for those patients. This group of patients might be particularly vulnerable to adverse events, including hospital readmission, given their suboptimal connection with their primary-care providers.

Hospitalists who practice entirely as inpatient physicians will not be able to bill these new codes, but they will provide a valuable service to patients by helping identify the physicians who will provide their TCM and documenting this in the discharge documentation, already seen as a key element of discharge day management services.

Do These Codes Change the Business Case for Discharge Clinics?

Discharge clinics, either hospitalist-staffed or otherwise, have been actively discussed in the media in recent years.¹ Even without these transitional codes, discharge clinics have arisen where primary-care access is limited and as a potential, but as yet unproven, solution to high readmission rates. Despite this proliferation, discharge clinics have not yet proven to be cost-effective.

Implementation of these codes could change the calculus for organizations considering dedicating resources to a discharge clinic. The new codes could make discharge clinics more financially viable by increasing the reimbursement for care that often requires more than 30 minutes. However, based on the experience in our clinic, the increased revenue accurately reflects the intensity of service necessary to coordinate care in the post-discharge period.

The time intensity of care already is obvious from the structure of established discharge clinics. Examples include the comprehensive care centers at HealthCare Partners in Southern California, where multidisciplinary visits average 90 minutes, or at our clinic at Beth Israel Deaconess Medical Center in Boston.² While the visits in our clinic are less than half as long as those at HealthCare Partners, we are not including the time spent reviewing the discharge documentation, outstanding tests, and medication changes in advance of the visit, and the time spent after the visit, coordinating the patient’s care with visiting nurses and elder service agencies.³

What’s Next?

Whether these codes lead to an increased interest in hospitalist-staffed discharge clinics or to primary-care development of robust transitional-care structures, these new codes will help focus resources and attention on increasing services, with the goal of improving patient care during a period of extreme vulnerability. This alone is something to be grateful for, whether you are a transitionalist, hospitalist, primary-care doctor, caregiver, or patient.

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center in Boston and an instructor in medicine at Harvard Medical School. She is medical director of BIDMC’s Health Care Associates Post Discharge Clinic.

References

1. Andrews M. Post-discharge clinics try to cut hospital readmissions by helping patients. Washington Post website. Available at: http://articles.washingtonpost.com/2011-12-19/national/35288219_1_readmissions-discharge-vulnerable-patients. Accessed Jan. 7, 2013.
2. Feder JL. Predictive modeling and team care for high-need patients at HealthCare Partners. Health Aff (Millwood). 2011;30(3):416-418.
3. Doctoroff L. Interval examination: establishment of a hospitalist-staffed discharge clinic. J Gen Intern Med. 2012;27(10):1377-1382.

In November 2012, the Center for Medicare & Medicaid Services (CMS) finalized its 2013 physician fee schedule with two new transitional-care-management (TCM) codes, 99495 and 99496. These codes provide reimbursement for transitional-care services to patients for 30 days after hospital discharge. CMS estimates that two-thirds of the 10 million Medicare patients discharged annually from hospitals will have TCM services provided by an outpatient doctor. Why might hospitalists be interested in these outpatient codes? Read on.

As a post-discharge provider in a primary-care-based discharge clinic, I can say the new Medicare transitional codes read like our job description. Because I’ve worked in a post-discharge clinic for the past three years, I have learned that post-discharge care requires time and resource allocation beyond routine outpatient care. Because of the unique population we see, on average we bill at a higher level than the rest of the practice. Yet we, like all outpatient providers, remain constrained by the existing billing structure, which is intimately connected to physician face-to-face visits.

Here’s an illustration of a typical afternoon in the post-discharge clinic: A schizophrenic patient presents with renal failure, hypoglycemia, and confusion. Her home visiting nurse (VNA) administers her medications; the patient cannot tell you any of them. While you are calling the VNA to clarify her medications, trying to identify her healthcare proxy, and stopping her ACE inhibitor because her potassium is 5.6, the next patient arrives. She has end-stage liver disease and was recently in the hospital for liver failure, and now has worsening recurrent ascites. After clinic, you call interventional radiology to coordinate a therapeutic paracentesis and change diuretic doses after her labs return. Two weeks later, you arrange a repeat paracentesis, and subsequently a transition to comfort care in a hospice house. For this work, right now, you can at most bill a high-complexity office visit (99215), and the rest of the care coordination—by you, your nurse, or your administrative staff—is not compensated.

How Do the New Codes Work?

CMS created the new TCM codes to begin to change the outpatient fee schedule to emphasize primary care and care coordination for beneficiaries, particularly in the post-hospitalization period. The new TCM codes are a first step toward reimbursement for non-face-to-face activities, which are increasingly important in the evolving healthcare system.

The investment is estimated at more than $1 billion in 2013. The new codes are available to physicians, physician assistants, nurse practitioners, and other advanced-practice nurses only once within the 30 days after hospital discharge. During the 30 days after discharge, the two codes, 99495 and 99496, require a single face-to-face visit within seven days of discharge for the highest-risk patients and within 14 days of discharge for moderate-risk patients. The face-to-face visit is not billed separately. The codes also mandate telephone communication with the patient or caregiver within two business days of hospital discharge; the medical decision-making must be of either moderate or high complexity.

The average reimbursement for the codes will be $132.96 for 99495 and $231.11 for 99496, reflecting a higher wRVU than either hospital discharge day management or high-acuity outpatient visits. The code is billed at the end of the 30 days. The TCM code cannot be billed a second time if a patient is readmitted within the 30 days. Other E/M codes can be billed during the same time period for additional visits as necessary.

What’s the Impact on Hospitalists?

The new codes affect hospitalists in two ways. First, the hospitalists in the growing group of “transitionalists,” many of whom practice in outpatient clinics seeing patients after discharge, will be able to use these codes. As the codes require no pre-existing relationship with the patient, non-primary-care providers will be able to bill these codes, assuming that they fulfill the designated requirements. This concession enables hospitalists to fill a vital role for those patients who have inadequate access to immediate primary care post-hospitalization. It also provides a necessary bridge to appropriate primary care for those patients. This group of patients might be particularly vulnerable to adverse events, including hospital readmission, given their suboptimal connection with their primary-care providers.

Hospitalists who practice entirely as inpatient physicians will not be able to bill these new codes, but they will provide a valuable service to patients by helping identify the physicians who will provide their TCM and documenting this in the discharge documentation, already seen as a key element of discharge day management services.

Do These Codes Change the Business Case for Discharge Clinics?

Discharge clinics, either hospitalist-staffed or otherwise, have been actively discussed in the media in recent years.¹ Even without these transitional codes, discharge clinics have arisen where primary-care access is limited and as a potential, but as yet unproven, solution to high readmission rates. Despite this proliferation, discharge clinics have not yet proven to be cost-effective.

Implementation of these codes could change the calculus for organizations considering dedicating resources to a discharge clinic. The new codes could make discharge clinics more financially viable by increasing the reimbursement for care that often requires more than 30 minutes. However, based on the experience in our clinic, the increased revenue accurately reflects the intensity of service necessary to coordinate care in the post-discharge period.

The time intensity of care already is obvious from the structure of established discharge clinics. Examples include the comprehensive care centers at HealthCare Partners in Southern California, where multidisciplinary visits average 90 minutes, or at our clinic at Beth Israel Deaconess Medical Center in Boston.² While the visits in our clinic are less than half as long as those at HealthCare Partners, we are not including the time spent reviewing the discharge documentation, outstanding tests, and medication changes in advance of the visit, and the time spent after the visit, coordinating the patient’s care with visiting nurses and elder service agencies.³

What’s Next?

Whether these codes lead to an increased interest in hospitalist-staffed discharge clinics or to primary-care development of robust transitional-care structures, these new codes will help focus resources and attention on increasing services, with the goal of improving patient care during a period of extreme vulnerability. This alone is something to be grateful for, whether you are a transitionalist, hospitalist, primary-care doctor, caregiver, or patient.

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center in Boston and an instructor in medicine at Harvard Medical School. She is medical director of BIDMC’s Health Care Associates Post Discharge Clinic.

References

1. Andrews M. Post-discharge clinics try to cut hospital readmissions by helping patients. Washington Post website. Available at: http://articles.washingtonpost.com/2011-12-19/national/35288219_1_readmissions-discharge-vulnerable-patients. Accessed Jan. 7, 2013.
2. Feder JL. Predictive modeling and team care for high-need patients at HealthCare Partners. Health Aff (Millwood). 2011;30(3):416-418.
3. Doctoroff L. Interval examination: establishment of a hospitalist-staffed discharge clinic. J Gen Intern Med. 2012;27(10):1377-1382.

In November 2012, the Center for Medicare & Medicaid Services (CMS) finalized its 2013 physician fee schedule with two new transitional-care-management (TCM) codes, 99495 and 99496. These codes provide reimbursement for transitional-care services to patients for 30 days after hospital discharge. CMS estimates that two-thirds of the 10 million Medicare patients discharged annually from hospitals will have TCM services provided by an outpatient doctor. Why might hospitalists be interested in these outpatient codes? Read on.

As a post-discharge provider in a primary-care-based discharge clinic, I can say the new Medicare transitional codes read like our job description. Because I’ve worked in a post-discharge clinic for the past three years, I have learned that post-discharge care requires time and resource allocation beyond routine outpatient care. Because of the unique population we see, on average we bill at a higher level than the rest of the practice. Yet we, like all outpatient providers, remain constrained by the existing billing structure, which is intimately connected to physician face-to-face visits.

Here’s an illustration of a typical afternoon in the post-discharge clinic: A schizophrenic patient presents with renal failure, hypoglycemia, and confusion. Her home visiting nurse (VNA) administers her medications; the patient cannot tell you any of them. While you are calling the VNA to clarify her medications, trying to identify her healthcare proxy, and stopping her ACE inhibitor because her potassium is 5.6, the next patient arrives. She has end-stage liver disease and was recently in the hospital for liver failure, and now has worsening recurrent ascites. After clinic, you call interventional radiology to coordinate a therapeutic paracentesis and change diuretic doses after her labs return. Two weeks later, you arrange a repeat paracentesis, and subsequently a transition to comfort care in a hospice house. For this work, right now, you can at most bill a high-complexity office visit (99215), and the rest of the care coordination—by you, your nurse, or your administrative staff—is not compensated.

How Do the New Codes Work?

CMS created the new TCM codes to begin to change the outpatient fee schedule to emphasize primary care and care coordination for beneficiaries, particularly in the post-hospitalization period. The new TCM codes are a first step toward reimbursement for non-face-to-face activities, which are increasingly important in the evolving healthcare system.

The investment is estimated at more than $1 billion in 2013. The new codes are available to physicians, physician assistants, nurse practitioners, and other advanced-practice nurses only once within the 30 days after hospital discharge. During the 30 days after discharge, the two codes, 99495 and 99496, require a single face-to-face visit within seven days of discharge for the highest-risk patients and within 14 days of discharge for moderate-risk patients. The face-to-face visit is not billed separately. The codes also mandate telephone communication with the patient or caregiver within two business days of hospital discharge; the medical decision-making must be of either moderate or high complexity.

The average reimbursement for the codes will be $132.96 for 99495 and $231.11 for 99496, reflecting a higher wRVU than either hospital discharge day management or high-acuity outpatient visits. The code is billed at the end of the 30 days. The TCM code cannot be billed a second time if a patient is readmitted within the 30 days. Other E/M codes can be billed during the same time period for additional visits as necessary.

What’s the Impact on Hospitalists?

The new codes affect hospitalists in two ways. First, the hospitalists in the growing group of “transitionalists,” many of whom practice in outpatient clinics seeing patients after discharge, will be able to use these codes. As the codes require no pre-existing relationship with the patient, non-primary-care providers will be able to bill these codes, assuming that they fulfill the designated requirements. This concession enables hospitalists to fill a vital role for those patients who have inadequate access to immediate primary care post-hospitalization. It also provides a necessary bridge to appropriate primary care for those patients. This group of patients might be particularly vulnerable to adverse events, including hospital readmission, given their suboptimal connection with their primary-care providers.

Hospitalists who practice entirely as inpatient physicians will not be able to bill these new codes, but they will provide a valuable service to patients by helping identify the physicians who will provide their TCM and documenting this in the discharge documentation, already seen as a key element of discharge day management services.

Do These Codes Change the Business Case for Discharge Clinics?

Discharge clinics, either hospitalist-staffed or otherwise, have been actively discussed in the media in recent years.¹ Even without these transitional codes, discharge clinics have arisen where primary-care access is limited and as a potential, but as yet unproven, solution to high readmission rates. Despite this proliferation, discharge clinics have not yet proven to be cost-effective.

Implementation of these codes could change the calculus for organizations considering dedicating resources to a discharge clinic. The new codes could make discharge clinics more financially viable by increasing the reimbursement for care that often requires more than 30 minutes. However, based on the experience in our clinic, the increased revenue accurately reflects the intensity of service necessary to coordinate care in the post-discharge period.

The time intensity of care already is obvious from the structure of established discharge clinics. Examples include the comprehensive care centers at HealthCare Partners in Southern California, where multidisciplinary visits average 90 minutes, or at our clinic at Beth Israel Deaconess Medical Center in Boston.² While the visits in our clinic are less than half as long as those at HealthCare Partners, we are not including the time spent reviewing the discharge documentation, outstanding tests, and medication changes in advance of the visit, and the time spent after the visit, coordinating the patient’s care with visiting nurses and elder service agencies.³

What’s Next?

Whether these codes lead to an increased interest in hospitalist-staffed discharge clinics or to primary-care development of robust transitional-care structures, these new codes will help focus resources and attention on increasing services, with the goal of improving patient care during a period of extreme vulnerability. This alone is something to be grateful for, whether you are a transitionalist, hospitalist, primary-care doctor, caregiver, or patient.

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center in Boston and an instructor in medicine at Harvard Medical School. She is medical director of BIDMC’s Health Care Associates Post Discharge Clinic.

References

1. Andrews M. Post-discharge clinics try to cut hospital readmissions by helping patients. Washington Post website. Available at: http://articles.washingtonpost.com/2011-12-19/national/35288219_1_readmissions-discharge-vulnerable-patients. Accessed Jan. 7, 2013.
2. Feder JL. Predictive modeling and team care for high-need patients at HealthCare Partners. Health Aff (Millwood). 2011;30(3):416-418.
3. Doctoroff L. Interval examination: establishment of a hospitalist-staffed discharge clinic. J Gen Intern Med. 2012;27(10):1377-1382.

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