Mixed Topics

When I started at the Society of Hospital Medicine – known then as the National Association of Inpatient Physicians (NAIP) – in January 2000, Bill Clinton was still president. There were probably 500 hospitalists in the United States, and SHM had about 200-250 members.

It was so long ago that the iPhone hadn’t been invented, Twitter wasn’t even an idea, and Amazon was an online book store. SHM’s national offices were a cubicle at the American College of Physicians headquarters in Philadelphia, and our entire staff was me and a part-time assistant.

We have certainly come a long way in my 20 years as CEO of SHM.

When I first became involved with NAIP, it was to help the board with their strategic planning in 1998. At that time, the national thought leaders for the hospitalist movement (the term hospital medicine had not been invented yet) predicted that hospitalists would eventually do the inpatient work for about 25% of family doctors and for 15% of internists. Hospitalists were considered to be a form of “general medicine” without an office-based practice.

One of the first things we set about doing was to define the new specialty of hospital medicine before anyone else (e.g., American Medical Association, ACP, American Academy of Family Physicians, American Academy of Pediatrics, the government) defined us.

Most specialties were defined by a body organ (e.g., cardiology, renal), a population (e.g., pediatrics, geriatrics), or a disease (e.g., oncology), and there were a few other site-specific specialties (e.g., ED medicine, critical care). We felt that, to be a specialty, we needed certain key elements:

• Separate group consciousness
• Professional society
• Distinct residency and fellowship programs
• Separate CME
• Distinct educational materials (e.g., textbooks)
• Definable and distinct competencies
• Separate credentials – certification and/or hospital insurance driven

Early on, SHM defined the Core Competencies for Hospital Medicine for adults in patient care and, eventually, for pediatric patients. We rebranded our specialty as hospital medicine to be more than just inpatient physicians, and to broadly encompass the growing “big tent” of SHM that included those trained in internal medicine, family medicine, pediatrics, med-peds, as well as nurse practitioners, physician assistants, pharmacists, and others.

We were the first and only specialty society to set the standard for hospitalist compensation (how much you are paid) and productivity (what you are expected to do) with our unique State of Hospital Medicine (SOHM) Report. Other specialties left this work to the Medical Group Management Association, the AMA, or commercial companies.

Our specialty was soon being asked to do things that no other group of clinicians was ever asked to do.

Hospitalists were expected to Save Money by reducing length of stay and the use of resources on the sickest patients. Hospitalists were asked to Improve Measurable Quality at a time when most other physicians or even hospitals weren’t even being measured.

We were expected to form and Lead Teams of other clinicians when health care was still seen as a solo enterprise. Hospitalists were expected to Improve Efficiency and to create a Seamless Continuity, both during the hospital stay and in the transitions out of the hospital.

Hospitalists were asked to do things no one else wanted to do, such as taking on the uncompensated patients and extra hospital committee work and just about any new project their hospital wanted to be involved in. Along the way, we were expected to Make Other Physicians’ Lives Better by taking on their inpatients, inpatient calls, comanagement with specialists, and unloading the ED.

And both at medical schools and in the community, hospitalists became the Major Educators of medical students, residents, nurses, and other hospital staff.

At the same time, SHM was focusing on becoming a very unique medical professional society.

SHM built on the energy of our young and innovative hospitalists to forge a different path. We had no reputation to protect. We were not bound like most other specialty societies to over 100 years of “the way it’s always been done.”

While other professional societies thought their role in quality improvement was to pontificate and publish clinical guidelines that often were little used, SHM embarked on an aggressive, hands-on, frontline approach by starting SHM’s Center for Quality Improvement. Over the last 15 years, the center has raised millions of dollars to deliver real change and improvement at hundreds of hospitals nationwide, many times bringing work plans and mentors to support and train local clinicians in quality improvement skills and data collection. This approach was recognized by the National Quality Forum and the Joint Commission with their prestigious John Eisenberg Award for Quality Improvement.

When we went to Washington to help shape the future of health care, we did not ask for more money for hospitalists. We did not ask for more power or to use regulations to protect our new specialty. Instead, we went with ideas of how to make acute medical care more effective and efficient. We could show the politicians and the regulators how we could reduce incidence of deep vein thrombosis and pulmonary emboli, how we could make the hospital discharge process work better, how we could help chart a smoother medication reconciliation process, and so many other ways the system could be improved.

And even the way SHM generated our new ideas was uniquely different than other specialties. Way back in 2000 – long before Twitter and other social media were able to crowdsource and use the Internet to percolate new ideas – SHM relied on our members’ conversations on the SHM electronic mail discussion list to see what hospitalists were worried about, and what everyone was being asked to do, and SHM provided the resources and initiatives to support our nation’s hospitalists.

From these early conversations, SHM heard that hospitalists were being asked to Lead Change without much of an idea of the skills they would need. And so, the SHM leadership academies were born, which have now educated more than 2,700 hospitalist leaders.

Early on, we learned that hospitalists and even their bosses had no idea of how to start or run a successful hospital medicine group. SHM started our practice management courses and webinars and we developed the groundbreaking document, Key Characteristics of Effective Hospital Medicine Groups. In a typical SHM manner, we challenged most of our members to improve and get better rather trying to defend the status quo. At SHM, we have constantly felt that hospital medicine was a “work in progress.” We may not be perfect today, but we will be better in 90 days and even better in a year.

I have more to say about how we got this far and even more to say about where we might go. So, stay tuned and keep contributing to the future and success of SHM and hospital medicine.

Dr. Wellikson is the CEO of SHM. He has announced his plan to retire from SHM in late 2020. This article is the first in a series celebrating Dr. Wellikson’s tenure as CEO.

When I started at the Society of Hospital Medicine – known then as the National Association of Inpatient Physicians (NAIP) – in January 2000, Bill Clinton was still president. There were probably 500 hospitalists in the United States, and SHM had about 200-250 members.

It was so long ago that the iPhone hadn’t been invented, Twitter wasn’t even an idea, and Amazon was an online book store. SHM’s national offices were a cubicle at the American College of Physicians headquarters in Philadelphia, and our entire staff was me and a part-time assistant.

We have certainly come a long way in my 20 years as CEO of SHM.

When I first became involved with NAIP, it was to help the board with their strategic planning in 1998. At that time, the national thought leaders for the hospitalist movement (the term hospital medicine had not been invented yet) predicted that hospitalists would eventually do the inpatient work for about 25% of family doctors and for 15% of internists. Hospitalists were considered to be a form of “general medicine” without an office-based practice.

One of the first things we set about doing was to define the new specialty of hospital medicine before anyone else (e.g., American Medical Association, ACP, American Academy of Family Physicians, American Academy of Pediatrics, the government) defined us.

Most specialties were defined by a body organ (e.g., cardiology, renal), a population (e.g., pediatrics, geriatrics), or a disease (e.g., oncology), and there were a few other site-specific specialties (e.g., ED medicine, critical care). We felt that, to be a specialty, we needed certain key elements:

• Separate group consciousness
• Professional society
• Distinct residency and fellowship programs
• Separate CME
• Distinct educational materials (e.g., textbooks)
• Definable and distinct competencies
• Separate credentials – certification and/or hospital insurance driven

Early on, SHM defined the Core Competencies for Hospital Medicine for adults in patient care and, eventually, for pediatric patients. We rebranded our specialty as hospital medicine to be more than just inpatient physicians, and to broadly encompass the growing “big tent” of SHM that included those trained in internal medicine, family medicine, pediatrics, med-peds, as well as nurse practitioners, physician assistants, pharmacists, and others.

We were the first and only specialty society to set the standard for hospitalist compensation (how much you are paid) and productivity (what you are expected to do) with our unique State of Hospital Medicine (SOHM) Report. Other specialties left this work to the Medical Group Management Association, the AMA, or commercial companies.

Our specialty was soon being asked to do things that no other group of clinicians was ever asked to do.

Hospitalists were expected to Save Money by reducing length of stay and the use of resources on the sickest patients. Hospitalists were asked to Improve Measurable Quality at a time when most other physicians or even hospitals weren’t even being measured.

We were expected to form and Lead Teams of other clinicians when health care was still seen as a solo enterprise. Hospitalists were expected to Improve Efficiency and to create a Seamless Continuity, both during the hospital stay and in the transitions out of the hospital.

Hospitalists were asked to do things no one else wanted to do, such as taking on the uncompensated patients and extra hospital committee work and just about any new project their hospital wanted to be involved in. Along the way, we were expected to Make Other Physicians’ Lives Better by taking on their inpatients, inpatient calls, comanagement with specialists, and unloading the ED.

And both at medical schools and in the community, hospitalists became the Major Educators of medical students, residents, nurses, and other hospital staff.

At the same time, SHM was focusing on becoming a very unique medical professional society.

SHM built on the energy of our young and innovative hospitalists to forge a different path. We had no reputation to protect. We were not bound like most other specialty societies to over 100 years of “the way it’s always been done.”

While other professional societies thought their role in quality improvement was to pontificate and publish clinical guidelines that often were little used, SHM embarked on an aggressive, hands-on, frontline approach by starting SHM’s Center for Quality Improvement. Over the last 15 years, the center has raised millions of dollars to deliver real change and improvement at hundreds of hospitals nationwide, many times bringing work plans and mentors to support and train local clinicians in quality improvement skills and data collection. This approach was recognized by the National Quality Forum and the Joint Commission with their prestigious John Eisenberg Award for Quality Improvement.

When we went to Washington to help shape the future of health care, we did not ask for more money for hospitalists. We did not ask for more power or to use regulations to protect our new specialty. Instead, we went with ideas of how to make acute medical care more effective and efficient. We could show the politicians and the regulators how we could reduce incidence of deep vein thrombosis and pulmonary emboli, how we could make the hospital discharge process work better, how we could help chart a smoother medication reconciliation process, and so many other ways the system could be improved.

And even the way SHM generated our new ideas was uniquely different than other specialties. Way back in 2000 – long before Twitter and other social media were able to crowdsource and use the Internet to percolate new ideas – SHM relied on our members’ conversations on the SHM electronic mail discussion list to see what hospitalists were worried about, and what everyone was being asked to do, and SHM provided the resources and initiatives to support our nation’s hospitalists.

From these early conversations, SHM heard that hospitalists were being asked to Lead Change without much of an idea of the skills they would need. And so, the SHM leadership academies were born, which have now educated more than 2,700 hospitalist leaders.

Early on, we learned that hospitalists and even their bosses had no idea of how to start or run a successful hospital medicine group. SHM started our practice management courses and webinars and we developed the groundbreaking document, Key Characteristics of Effective Hospital Medicine Groups. In a typical SHM manner, we challenged most of our members to improve and get better rather trying to defend the status quo. At SHM, we have constantly felt that hospital medicine was a “work in progress.” We may not be perfect today, but we will be better in 90 days and even better in a year.

I have more to say about how we got this far and even more to say about where we might go. So, stay tuned and keep contributing to the future and success of SHM and hospital medicine.

Dr. Wellikson is the CEO of SHM. He has announced his plan to retire from SHM in late 2020. This article is the first in a series celebrating Dr. Wellikson’s tenure as CEO.

When I started at the Society of Hospital Medicine – known then as the National Association of Inpatient Physicians (NAIP) – in January 2000, Bill Clinton was still president. There were probably 500 hospitalists in the United States, and SHM had about 200-250 members.

It was so long ago that the iPhone hadn’t been invented, Twitter wasn’t even an idea, and Amazon was an online book store. SHM’s national offices were a cubicle at the American College of Physicians headquarters in Philadelphia, and our entire staff was me and a part-time assistant.

We have certainly come a long way in my 20 years as CEO of SHM.

When I first became involved with NAIP, it was to help the board with their strategic planning in 1998. At that time, the national thought leaders for the hospitalist movement (the term hospital medicine had not been invented yet) predicted that hospitalists would eventually do the inpatient work for about 25% of family doctors and for 15% of internists. Hospitalists were considered to be a form of “general medicine” without an office-based practice.

One of the first things we set about doing was to define the new specialty of hospital medicine before anyone else (e.g., American Medical Association, ACP, American Academy of Family Physicians, American Academy of Pediatrics, the government) defined us.

Most specialties were defined by a body organ (e.g., cardiology, renal), a population (e.g., pediatrics, geriatrics), or a disease (e.g., oncology), and there were a few other site-specific specialties (e.g., ED medicine, critical care). We felt that, to be a specialty, we needed certain key elements:

• Separate group consciousness
• Professional society
• Distinct residency and fellowship programs
• Separate CME
• Distinct educational materials (e.g., textbooks)
• Definable and distinct competencies
• Separate credentials – certification and/or hospital insurance driven

Early on, SHM defined the Core Competencies for Hospital Medicine for adults in patient care and, eventually, for pediatric patients. We rebranded our specialty as hospital medicine to be more than just inpatient physicians, and to broadly encompass the growing “big tent” of SHM that included those trained in internal medicine, family medicine, pediatrics, med-peds, as well as nurse practitioners, physician assistants, pharmacists, and others.

We were the first and only specialty society to set the standard for hospitalist compensation (how much you are paid) and productivity (what you are expected to do) with our unique State of Hospital Medicine (SOHM) Report. Other specialties left this work to the Medical Group Management Association, the AMA, or commercial companies.

Our specialty was soon being asked to do things that no other group of clinicians was ever asked to do.

Hospitalists were expected to Save Money by reducing length of stay and the use of resources on the sickest patients. Hospitalists were asked to Improve Measurable Quality at a time when most other physicians or even hospitals weren’t even being measured.

We were expected to form and Lead Teams of other clinicians when health care was still seen as a solo enterprise. Hospitalists were expected to Improve Efficiency and to create a Seamless Continuity, both during the hospital stay and in the transitions out of the hospital.

Hospitalists were asked to do things no one else wanted to do, such as taking on the uncompensated patients and extra hospital committee work and just about any new project their hospital wanted to be involved in. Along the way, we were expected to Make Other Physicians’ Lives Better by taking on their inpatients, inpatient calls, comanagement with specialists, and unloading the ED.

And both at medical schools and in the community, hospitalists became the Major Educators of medical students, residents, nurses, and other hospital staff.

At the same time, SHM was focusing on becoming a very unique medical professional society.

SHM built on the energy of our young and innovative hospitalists to forge a different path. We had no reputation to protect. We were not bound like most other specialty societies to over 100 years of “the way it’s always been done.”

While other professional societies thought their role in quality improvement was to pontificate and publish clinical guidelines that often were little used, SHM embarked on an aggressive, hands-on, frontline approach by starting SHM’s Center for Quality Improvement. Over the last 15 years, the center has raised millions of dollars to deliver real change and improvement at hundreds of hospitals nationwide, many times bringing work plans and mentors to support and train local clinicians in quality improvement skills and data collection. This approach was recognized by the National Quality Forum and the Joint Commission with their prestigious John Eisenberg Award for Quality Improvement.

When we went to Washington to help shape the future of health care, we did not ask for more money for hospitalists. We did not ask for more power or to use regulations to protect our new specialty. Instead, we went with ideas of how to make acute medical care more effective and efficient. We could show the politicians and the regulators how we could reduce incidence of deep vein thrombosis and pulmonary emboli, how we could make the hospital discharge process work better, how we could help chart a smoother medication reconciliation process, and so many other ways the system could be improved.

And even the way SHM generated our new ideas was uniquely different than other specialties. Way back in 2000 – long before Twitter and other social media were able to crowdsource and use the Internet to percolate new ideas – SHM relied on our members’ conversations on the SHM electronic mail discussion list to see what hospitalists were worried about, and what everyone was being asked to do, and SHM provided the resources and initiatives to support our nation’s hospitalists.

From these early conversations, SHM heard that hospitalists were being asked to Lead Change without much of an idea of the skills they would need. And so, the SHM leadership academies were born, which have now educated more than 2,700 hospitalist leaders.

Early on, we learned that hospitalists and even their bosses had no idea of how to start or run a successful hospital medicine group. SHM started our practice management courses and webinars and we developed the groundbreaking document, Key Characteristics of Effective Hospital Medicine Groups. In a typical SHM manner, we challenged most of our members to improve and get better rather trying to defend the status quo. At SHM, we have constantly felt that hospital medicine was a “work in progress.” We may not be perfect today, but we will be better in 90 days and even better in a year.

I have more to say about how we got this far and even more to say about where we might go. So, stay tuned and keep contributing to the future and success of SHM and hospital medicine.

Dr. Wellikson is the CEO of SHM. He has announced his plan to retire from SHM in late 2020. This article is the first in a series celebrating Dr. Wellikson’s tenure as CEO.

The most rural counties in the United States had higher percentages of potentially preventable deaths from the five leading causes of mortality, compared with the most urban counties during 2010-2017, according to study published in CDC’s Morbidity and Mortality Weekly Report.

These leading causes of death comprised heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke and accounted for approximately 1.7 million deaths or 61% of all deaths in 2017.

The study presents estimates, percentages, and annual percent changes for potentially excess deaths by urban-rural classification from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Urban-rural categories were identified using the National Center for Health Statistics 2013 urban-rural classification scheme for counties.

The report’s main findings include the following statistics:

• In 2010, 28.7% of deaths from cancer in the most rural counties were potentially preventable, compared with 17.9% in the most urban counties. By 2017, 21.7% of cancer deaths in the most rural counties were potentially preventable, compared with 3.2% in the most urban counties.
• In 2010, 45.1% of deaths from heart disease in the most rural counties were potentially preventable, compared with 33.5% in the most urban counties. By 2017, 44.9% of deaths from heart disease in the most rural counties were potentially preventable, compared with 28.0% in the most urban counties.
• In 2010, 60.9% of deaths from unintentional injury in the most rural counties were potentially preventable, compared with 25.4% in the most urban counties. By 2017, 64.1% of deaths from unintentional injury in the most rural counties were potentially preventable, compared with 47.8% in the most urban counties.
• In 2010, 54.3% of deaths from chronic lower respiratory disease (such as COPD) in the most rural counties were potentially preventable, compared with 23.4% in the most urban counties. By 2017, 57.1% of deaths from chronic lower respiratory disease in the most rural counties were potentially preventable, compared with 13% in the most urban counties.
• In 2010, 41.6% of deaths from stroke in the most rural counties were potentially preventable, compared with 31.7% in most urban areas. By 2017, 37.8% of deaths from stroke in the most rural counties were potentially preventable, compared with 27.4% most urban counties.

“This report demonstrates the value of analyzing potentially excess deaths according to the six 2013 [National Center for Health Statistics] urban-rural county classifications. Reporting trends in potentially excess deaths over an 8-year period highlights differences over time, independent of traditional underlying structural, environmental, and genetic factors,” wrote Macarena C. Garcia, DrPH, and coauthors.

“Because of increasing percentages of potentially excess deaths in recent years for certain causes of death and certain demographic groups, these data can be used, with traditional rate comparisons, by public health practitioners who are involved in planning interventions. Comparing the findings in this report with data from tools such as the CDC Interactive Atlas of Heart Disease and Stroke might help identify the social determinants, health care infrastructures, and public policies that could increase or decrease numbers of deaths in specific nonmetropolitan areas,” they added.

The study authors did not disclose any potential conflicts of interest.
 

[email protected]

SOURCE: Garcia MC et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 8: 68(10);1-11.

The most rural counties in the United States had higher percentages of potentially preventable deaths from the five leading causes of mortality, compared with the most urban counties during 2010-2017, according to study published in CDC’s Morbidity and Mortality Weekly Report.

These leading causes of death comprised heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke and accounted for approximately 1.7 million deaths or 61% of all deaths in 2017.

The study presents estimates, percentages, and annual percent changes for potentially excess deaths by urban-rural classification from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Urban-rural categories were identified using the National Center for Health Statistics 2013 urban-rural classification scheme for counties.

The report’s main findings include the following statistics:

• In 2010, 28.7% of deaths from cancer in the most rural counties were potentially preventable, compared with 17.9% in the most urban counties. By 2017, 21.7% of cancer deaths in the most rural counties were potentially preventable, compared with 3.2% in the most urban counties.
• In 2010, 45.1% of deaths from heart disease in the most rural counties were potentially preventable, compared with 33.5% in the most urban counties. By 2017, 44.9% of deaths from heart disease in the most rural counties were potentially preventable, compared with 28.0% in the most urban counties.
• In 2010, 60.9% of deaths from unintentional injury in the most rural counties were potentially preventable, compared with 25.4% in the most urban counties. By 2017, 64.1% of deaths from unintentional injury in the most rural counties were potentially preventable, compared with 47.8% in the most urban counties.
• In 2010, 54.3% of deaths from chronic lower respiratory disease (such as COPD) in the most rural counties were potentially preventable, compared with 23.4% in the most urban counties. By 2017, 57.1% of deaths from chronic lower respiratory disease in the most rural counties were potentially preventable, compared with 13% in the most urban counties.
• In 2010, 41.6% of deaths from stroke in the most rural counties were potentially preventable, compared with 31.7% in most urban areas. By 2017, 37.8% of deaths from stroke in the most rural counties were potentially preventable, compared with 27.4% most urban counties.

“This report demonstrates the value of analyzing potentially excess deaths according to the six 2013 [National Center for Health Statistics] urban-rural county classifications. Reporting trends in potentially excess deaths over an 8-year period highlights differences over time, independent of traditional underlying structural, environmental, and genetic factors,” wrote Macarena C. Garcia, DrPH, and coauthors.

“Because of increasing percentages of potentially excess deaths in recent years for certain causes of death and certain demographic groups, these data can be used, with traditional rate comparisons, by public health practitioners who are involved in planning interventions. Comparing the findings in this report with data from tools such as the CDC Interactive Atlas of Heart Disease and Stroke might help identify the social determinants, health care infrastructures, and public policies that could increase or decrease numbers of deaths in specific nonmetropolitan areas,” they added.

The study authors did not disclose any potential conflicts of interest.
 

[email protected]

SOURCE: Garcia MC et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 8: 68(10);1-11.

The most rural counties in the United States had higher percentages of potentially preventable deaths from the five leading causes of mortality, compared with the most urban counties during 2010-2017, according to study published in CDC’s Morbidity and Mortality Weekly Report.

These leading causes of death comprised heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke and accounted for approximately 1.7 million deaths or 61% of all deaths in 2017.

The study presents estimates, percentages, and annual percent changes for potentially excess deaths by urban-rural classification from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Urban-rural categories were identified using the National Center for Health Statistics 2013 urban-rural classification scheme for counties.

The report’s main findings include the following statistics:

• In 2010, 28.7% of deaths from cancer in the most rural counties were potentially preventable, compared with 17.9% in the most urban counties. By 2017, 21.7% of cancer deaths in the most rural counties were potentially preventable, compared with 3.2% in the most urban counties.
• In 2010, 45.1% of deaths from heart disease in the most rural counties were potentially preventable, compared with 33.5% in the most urban counties. By 2017, 44.9% of deaths from heart disease in the most rural counties were potentially preventable, compared with 28.0% in the most urban counties.
• In 2010, 60.9% of deaths from unintentional injury in the most rural counties were potentially preventable, compared with 25.4% in the most urban counties. By 2017, 64.1% of deaths from unintentional injury in the most rural counties were potentially preventable, compared with 47.8% in the most urban counties.
• In 2010, 54.3% of deaths from chronic lower respiratory disease (such as COPD) in the most rural counties were potentially preventable, compared with 23.4% in the most urban counties. By 2017, 57.1% of deaths from chronic lower respiratory disease in the most rural counties were potentially preventable, compared with 13% in the most urban counties.
• In 2010, 41.6% of deaths from stroke in the most rural counties were potentially preventable, compared with 31.7% in most urban areas. By 2017, 37.8% of deaths from stroke in the most rural counties were potentially preventable, compared with 27.4% most urban counties.

“This report demonstrates the value of analyzing potentially excess deaths according to the six 2013 [National Center for Health Statistics] urban-rural county classifications. Reporting trends in potentially excess deaths over an 8-year period highlights differences over time, independent of traditional underlying structural, environmental, and genetic factors,” wrote Macarena C. Garcia, DrPH, and coauthors.

“Because of increasing percentages of potentially excess deaths in recent years for certain causes of death and certain demographic groups, these data can be used, with traditional rate comparisons, by public health practitioners who are involved in planning interventions. Comparing the findings in this report with data from tools such as the CDC Interactive Atlas of Heart Disease and Stroke might help identify the social determinants, health care infrastructures, and public policies that could increase or decrease numbers of deaths in specific nonmetropolitan areas,” they added.

The study authors did not disclose any potential conflicts of interest.
 

[email protected]

SOURCE: Garcia MC et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 8: 68(10);1-11.

Dear Colleagues,

Forty years ago, dermatology practice was different. No patient came to the office for a “full-body check,” nor did anyone show up for hair removal or questions about cosmetic procedures or skin care advice.

Needle nippers were around, but no elaborate, molded-plastic contraptions like the sharps containers now in wide use. You sent pathology specimens in plastic cylinders by U.S. mail; then you called the lab 2 weeks later to ask, “Where’s the report on Jane Smith, with the rule out melanoma,” and the lab said, “Jane who?”

Of course, some things about practice have not changed. Patients with atopic dermatitis still ask why eczema comes back and why we can’t give them something to make it go away once and for all. Some referring physicians still treat scaly rashes with ketoconazole cream (and when that fails, oral fluconazole, which doesn’t work either).

Of course the biggest change between then and now, coincident with the rise of computers and technology, is the advent and ubiquity of that great swindle foisted upon the profession and the public – electronic health records – with their unfulfilled promises of cost-savings and efficiency and unconceded consequences: turning healers into harried data-entry drudges too busy clicking mice to make eye contact with humans. Yes, the Emperor has clothes. The Emperor is wearing Depends.

I wrote my first column for this periodical 22 years ago; this will be my last. My wonderful editor, Elizabeth Mechcatie, has agreed to take under advisement a proposal that I go on sending occasional dispatches under the heading “Pruritus Emeritus.” My family used to refer to those in the anomalous state of being emeritus – it means, roughly, “Forgotten, but not gone” – by rhyming emeritus with sinusitis.

There is no way to remember 40 years of patients. Many came just once, others several times. Some moved away, some passed away, changed primary doctors, changed insurances. Some grew too old to visit, sent regretful notes apologizing for finding the drive too long, the parking too hard. Some returned after an absence of a decade or 3, having forgotten that they had once come for the same problem, or come at all.

But there have been other patients who formed a real bond, whose names and faces still come readily to mind, who visited over long periods, sent their spouses, family members, even children and grandchildren. The stories of their lives became part of mine, and sometimes mine part of theirs.

Though hardly an old-movie buff, I know the famous scene in Casablanca in which a radiant Ingrid Bergman (that skin!) asks Dooley Wilson – the piano player, Sam – to play the song Humphrey Bogart does not want to hear:

“You must remember this

A kiss is just a kiss

A sigh is just a sigh

The fundamental things apply

As time goes by.”

Over the last 40 years there have been substantial advances in the way we treat patients, though perhaps not enough to justify the endless noisy hype about imminent breakthroughs and looming disruptions, therapies, and apps that are sure to change practice and civilization as we know them. Altogether too much noise, at least for my taste. But not inside the examining room.

Outside the room rages the din of demographic updates, of online checks of insurance eligibility, referral status, prior authorizations, the blare of marketing and promotion, the cacophony of metrics and algorithms.

Inside the room, however, quiet reigns. A patient presents with a symptom or a sign, or the fear of a symptom or anxiety over the meaning of a sign, filtered through a jumble of ideas – misremembered, half understood, at times mutually contradictory – that amplify fears common to anyone who visits a practitioner, however minor the presenting complaint: pain, debility, decline, isolation, solitude, death.

And the practitioner attends, considers, contextualizes, counsels, consoles, and conveys a response to the patient’s questions, whether in so many words or by body language or tone of voice, offers answers not just to what the patient has asked but the ones the patient meant to ask but did not know how.

“Yes, sir, death waits for all of us in the end, but for you, perhaps, not today.”

“Yes, madam, illness can be a frightening affair, but your case is not as bad as you think it is and won’t move as fast as you imagine. And as to your being limited and alone – well, not yet. There are those you can rely on, people with a bit of knowledge and a little experience, who are committed to doing what can be done to bend the arc of illness in your favor.”

That fundamental role will, it seems to me, always apply as long people practice medicine.

With all good wishes for personal happiness and professional success,

Alan Rockoff
 

Dear Colleagues,

Forty years ago, dermatology practice was different. No patient came to the office for a “full-body check,” nor did anyone show up for hair removal or questions about cosmetic procedures or skin care advice.

Needle nippers were around, but no elaborate, molded-plastic contraptions like the sharps containers now in wide use. You sent pathology specimens in plastic cylinders by U.S. mail; then you called the lab 2 weeks later to ask, “Where’s the report on Jane Smith, with the rule out melanoma,” and the lab said, “Jane who?”

Of course, some things about practice have not changed. Patients with atopic dermatitis still ask why eczema comes back and why we can’t give them something to make it go away once and for all. Some referring physicians still treat scaly rashes with ketoconazole cream (and when that fails, oral fluconazole, which doesn’t work either).

Of course the biggest change between then and now, coincident with the rise of computers and technology, is the advent and ubiquity of that great swindle foisted upon the profession and the public – electronic health records – with their unfulfilled promises of cost-savings and efficiency and unconceded consequences: turning healers into harried data-entry drudges too busy clicking mice to make eye contact with humans. Yes, the Emperor has clothes. The Emperor is wearing Depends.

I wrote my first column for this periodical 22 years ago; this will be my last. My wonderful editor, Elizabeth Mechcatie, has agreed to take under advisement a proposal that I go on sending occasional dispatches under the heading “Pruritus Emeritus.” My family used to refer to those in the anomalous state of being emeritus – it means, roughly, “Forgotten, but not gone” – by rhyming emeritus with sinusitis.

There is no way to remember 40 years of patients. Many came just once, others several times. Some moved away, some passed away, changed primary doctors, changed insurances. Some grew too old to visit, sent regretful notes apologizing for finding the drive too long, the parking too hard. Some returned after an absence of a decade or 3, having forgotten that they had once come for the same problem, or come at all.

But there have been other patients who formed a real bond, whose names and faces still come readily to mind, who visited over long periods, sent their spouses, family members, even children and grandchildren. The stories of their lives became part of mine, and sometimes mine part of theirs.

Though hardly an old-movie buff, I know the famous scene in Casablanca in which a radiant Ingrid Bergman (that skin!) asks Dooley Wilson – the piano player, Sam – to play the song Humphrey Bogart does not want to hear:

“You must remember this

A kiss is just a kiss

A sigh is just a sigh

The fundamental things apply

As time goes by.”

Over the last 40 years there have been substantial advances in the way we treat patients, though perhaps not enough to justify the endless noisy hype about imminent breakthroughs and looming disruptions, therapies, and apps that are sure to change practice and civilization as we know them. Altogether too much noise, at least for my taste. But not inside the examining room.

Outside the room rages the din of demographic updates, of online checks of insurance eligibility, referral status, prior authorizations, the blare of marketing and promotion, the cacophony of metrics and algorithms.

Inside the room, however, quiet reigns. A patient presents with a symptom or a sign, or the fear of a symptom or anxiety over the meaning of a sign, filtered through a jumble of ideas – misremembered, half understood, at times mutually contradictory – that amplify fears common to anyone who visits a practitioner, however minor the presenting complaint: pain, debility, decline, isolation, solitude, death.

And the practitioner attends, considers, contextualizes, counsels, consoles, and conveys a response to the patient’s questions, whether in so many words or by body language or tone of voice, offers answers not just to what the patient has asked but the ones the patient meant to ask but did not know how.

“Yes, sir, death waits for all of us in the end, but for you, perhaps, not today.”

“Yes, madam, illness can be a frightening affair, but your case is not as bad as you think it is and won’t move as fast as you imagine. And as to your being limited and alone – well, not yet. There are those you can rely on, people with a bit of knowledge and a little experience, who are committed to doing what can be done to bend the arc of illness in your favor.”

That fundamental role will, it seems to me, always apply as long people practice medicine.

With all good wishes for personal happiness and professional success,

Alan Rockoff
 

Dear Colleagues,

Forty years ago, dermatology practice was different. No patient came to the office for a “full-body check,” nor did anyone show up for hair removal or questions about cosmetic procedures or skin care advice.

Needle nippers were around, but no elaborate, molded-plastic contraptions like the sharps containers now in wide use. You sent pathology specimens in plastic cylinders by U.S. mail; then you called the lab 2 weeks later to ask, “Where’s the report on Jane Smith, with the rule out melanoma,” and the lab said, “Jane who?”

Of course, some things about practice have not changed. Patients with atopic dermatitis still ask why eczema comes back and why we can’t give them something to make it go away once and for all. Some referring physicians still treat scaly rashes with ketoconazole cream (and when that fails, oral fluconazole, which doesn’t work either).

Of course the biggest change between then and now, coincident with the rise of computers and technology, is the advent and ubiquity of that great swindle foisted upon the profession and the public – electronic health records – with their unfulfilled promises of cost-savings and efficiency and unconceded consequences: turning healers into harried data-entry drudges too busy clicking mice to make eye contact with humans. Yes, the Emperor has clothes. The Emperor is wearing Depends.

I wrote my first column for this periodical 22 years ago; this will be my last. My wonderful editor, Elizabeth Mechcatie, has agreed to take under advisement a proposal that I go on sending occasional dispatches under the heading “Pruritus Emeritus.” My family used to refer to those in the anomalous state of being emeritus – it means, roughly, “Forgotten, but not gone” – by rhyming emeritus with sinusitis.

There is no way to remember 40 years of patients. Many came just once, others several times. Some moved away, some passed away, changed primary doctors, changed insurances. Some grew too old to visit, sent regretful notes apologizing for finding the drive too long, the parking too hard. Some returned after an absence of a decade or 3, having forgotten that they had once come for the same problem, or come at all.

But there have been other patients who formed a real bond, whose names and faces still come readily to mind, who visited over long periods, sent their spouses, family members, even children and grandchildren. The stories of their lives became part of mine, and sometimes mine part of theirs.

Though hardly an old-movie buff, I know the famous scene in Casablanca in which a radiant Ingrid Bergman (that skin!) asks Dooley Wilson – the piano player, Sam – to play the song Humphrey Bogart does not want to hear:

“You must remember this

A kiss is just a kiss

A sigh is just a sigh

The fundamental things apply

As time goes by.”

Over the last 40 years there have been substantial advances in the way we treat patients, though perhaps not enough to justify the endless noisy hype about imminent breakthroughs and looming disruptions, therapies, and apps that are sure to change practice and civilization as we know them. Altogether too much noise, at least for my taste. But not inside the examining room.

Outside the room rages the din of demographic updates, of online checks of insurance eligibility, referral status, prior authorizations, the blare of marketing and promotion, the cacophony of metrics and algorithms.

Inside the room, however, quiet reigns. A patient presents with a symptom or a sign, or the fear of a symptom or anxiety over the meaning of a sign, filtered through a jumble of ideas – misremembered, half understood, at times mutually contradictory – that amplify fears common to anyone who visits a practitioner, however minor the presenting complaint: pain, debility, decline, isolation, solitude, death.

And the practitioner attends, considers, contextualizes, counsels, consoles, and conveys a response to the patient’s questions, whether in so many words or by body language or tone of voice, offers answers not just to what the patient has asked but the ones the patient meant to ask but did not know how.

“Yes, sir, death waits for all of us in the end, but for you, perhaps, not today.”

“Yes, madam, illness can be a frightening affair, but your case is not as bad as you think it is and won’t move as fast as you imagine. And as to your being limited and alone – well, not yet. There are those you can rely on, people with a bit of knowledge and a little experience, who are committed to doing what can be done to bend the arc of illness in your favor.”

That fundamental role will, it seems to me, always apply as long people practice medicine.

With all good wishes for personal happiness and professional success,

Alan Rockoff
 

SAN ANTONIO – Clinicians don’t appear to mind too much when their red blood cell orders are flagged for review by a best practice alert system, and alert fatigue doesn’t seem to hamper patient blood management efforts, investigators in a single-center study reported.

Neil Osterweil/MDedge News

At the Medical University of South Carolina, Charleston (MUSC), if clinicians order RBC transfusions for patients with hemoglobin levels over 7.0 g/dL or for patients who did not have a hemoglobin determination over the past 24 hours, they receive a best practice alert. They must acknowledge it and cancel the order, or override it and document a reason in the medical record.

Although approximately 70% of alerts were overridden, the reasons for the overrides “were consistent over time and appropriate,” reported Jerry E. Squires, MD, PhD, and colleagues from MUSC in a poster presentation at the annual meeting of AABB, the group formerly known as the American Association of Blood Banks.

The goal of the study was to find out if the effectiveness of the alert was wearing out after months of active use by clinicians. “Is it true that they’re clicking too much and they’re inundated with other [best practice alerts], and are they even paying attention?” said coauthor Heather Toeppner, RN, also from MUSC, in an interview. “All in all, we found that the alert is making a lasting impression in our institution,” she said.

Transfusion clinical decision support systems that produce automated alerts for clinicians can improve usage and reduce waste of RBCs, but whether the effect is sustained over time was unknown, Ms. Toeppner said, prompting the investigators to study the effect of the RBC best practice alert over 10 months.

As noted, the alert is triggered when providers order RBCs for patients with hemoglobin levels over 7.0 g/dL or when there is no record of a hemoglobin test in the chart within the past 24 hours. Before the alert is triggered, however, the system reviews the record and excludes alerts for patients with specific conditions, such as concurrent surgery or sickle cell disease.

The authors found that the alert was triggered an average of 195 times per month over the 10 months studied. On average, 16% of the alerts resulted in a cancellation of the RBC order, and 71% of alerts were overridden.

“Most importantly, there was no trend suggesting that either cancellation of the RBC order or overriding the alert became more frequent over time,” the investigators wrote. “Similarly, reasons for overriding the alert were consistent over time, with ‘preparation for an invasive procedure’ and ‘active bleeding’ being the most common reasons for overriding the alert (32% and 23% of all overrides, respectively).”

Other common reasons for overrides included tachycardia, shortness of breath, hypotension, onset of chest pain, and acute coronary syndrome.

Interestingly, but perhaps not surprisingly, they found that overrides dropped sharply and changed orders rose by the same magnitude in July, when new residents started their rotations.

The investigators wrote that the relatively small number of alerts may be attributable to their institution’s robust patient blood management program and the intentional exclusion of orders for patients with specific diagnostic codes, including intraoperative patients, those with sickle cell disease, and all patients aged younger than 18 years.

The study was internally funded. The authors reported having no conflicts of interest.

SAN ANTONIO – Clinicians don’t appear to mind too much when their red blood cell orders are flagged for review by a best practice alert system, and alert fatigue doesn’t seem to hamper patient blood management efforts, investigators in a single-center study reported.

Neil Osterweil/MDedge News

At the Medical University of South Carolina, Charleston (MUSC), if clinicians order RBC transfusions for patients with hemoglobin levels over 7.0 g/dL or for patients who did not have a hemoglobin determination over the past 24 hours, they receive a best practice alert. They must acknowledge it and cancel the order, or override it and document a reason in the medical record.

Although approximately 70% of alerts were overridden, the reasons for the overrides “were consistent over time and appropriate,” reported Jerry E. Squires, MD, PhD, and colleagues from MUSC in a poster presentation at the annual meeting of AABB, the group formerly known as the American Association of Blood Banks.

The goal of the study was to find out if the effectiveness of the alert was wearing out after months of active use by clinicians. “Is it true that they’re clicking too much and they’re inundated with other [best practice alerts], and are they even paying attention?” said coauthor Heather Toeppner, RN, also from MUSC, in an interview. “All in all, we found that the alert is making a lasting impression in our institution,” she said.

Transfusion clinical decision support systems that produce automated alerts for clinicians can improve usage and reduce waste of RBCs, but whether the effect is sustained over time was unknown, Ms. Toeppner said, prompting the investigators to study the effect of the RBC best practice alert over 10 months.

As noted, the alert is triggered when providers order RBCs for patients with hemoglobin levels over 7.0 g/dL or when there is no record of a hemoglobin test in the chart within the past 24 hours. Before the alert is triggered, however, the system reviews the record and excludes alerts for patients with specific conditions, such as concurrent surgery or sickle cell disease.

The authors found that the alert was triggered an average of 195 times per month over the 10 months studied. On average, 16% of the alerts resulted in a cancellation of the RBC order, and 71% of alerts were overridden.

“Most importantly, there was no trend suggesting that either cancellation of the RBC order or overriding the alert became more frequent over time,” the investigators wrote. “Similarly, reasons for overriding the alert were consistent over time, with ‘preparation for an invasive procedure’ and ‘active bleeding’ being the most common reasons for overriding the alert (32% and 23% of all overrides, respectively).”

Other common reasons for overrides included tachycardia, shortness of breath, hypotension, onset of chest pain, and acute coronary syndrome.

Interestingly, but perhaps not surprisingly, they found that overrides dropped sharply and changed orders rose by the same magnitude in July, when new residents started their rotations.

The investigators wrote that the relatively small number of alerts may be attributable to their institution’s robust patient blood management program and the intentional exclusion of orders for patients with specific diagnostic codes, including intraoperative patients, those with sickle cell disease, and all patients aged younger than 18 years.

The study was internally funded. The authors reported having no conflicts of interest.

SAN ANTONIO – Clinicians don’t appear to mind too much when their red blood cell orders are flagged for review by a best practice alert system, and alert fatigue doesn’t seem to hamper patient blood management efforts, investigators in a single-center study reported.

Neil Osterweil/MDedge News

At the Medical University of South Carolina, Charleston (MUSC), if clinicians order RBC transfusions for patients with hemoglobin levels over 7.0 g/dL or for patients who did not have a hemoglobin determination over the past 24 hours, they receive a best practice alert. They must acknowledge it and cancel the order, or override it and document a reason in the medical record.

Although approximately 70% of alerts were overridden, the reasons for the overrides “were consistent over time and appropriate,” reported Jerry E. Squires, MD, PhD, and colleagues from MUSC in a poster presentation at the annual meeting of AABB, the group formerly known as the American Association of Blood Banks.

The goal of the study was to find out if the effectiveness of the alert was wearing out after months of active use by clinicians. “Is it true that they’re clicking too much and they’re inundated with other [best practice alerts], and are they even paying attention?” said coauthor Heather Toeppner, RN, also from MUSC, in an interview. “All in all, we found that the alert is making a lasting impression in our institution,” she said.

Transfusion clinical decision support systems that produce automated alerts for clinicians can improve usage and reduce waste of RBCs, but whether the effect is sustained over time was unknown, Ms. Toeppner said, prompting the investigators to study the effect of the RBC best practice alert over 10 months.

As noted, the alert is triggered when providers order RBCs for patients with hemoglobin levels over 7.0 g/dL or when there is no record of a hemoglobin test in the chart within the past 24 hours. Before the alert is triggered, however, the system reviews the record and excludes alerts for patients with specific conditions, such as concurrent surgery or sickle cell disease.

The authors found that the alert was triggered an average of 195 times per month over the 10 months studied. On average, 16% of the alerts resulted in a cancellation of the RBC order, and 71% of alerts were overridden.

“Most importantly, there was no trend suggesting that either cancellation of the RBC order or overriding the alert became more frequent over time,” the investigators wrote. “Similarly, reasons for overriding the alert were consistent over time, with ‘preparation for an invasive procedure’ and ‘active bleeding’ being the most common reasons for overriding the alert (32% and 23% of all overrides, respectively).”

Other common reasons for overrides included tachycardia, shortness of breath, hypotension, onset of chest pain, and acute coronary syndrome.

Interestingly, but perhaps not surprisingly, they found that overrides dropped sharply and changed orders rose by the same magnitude in July, when new residents started their rotations.

The investigators wrote that the relatively small number of alerts may be attributable to their institution’s robust patient blood management program and the intentional exclusion of orders for patients with specific diagnostic codes, including intraoperative patients, those with sickle cell disease, and all patients aged younger than 18 years.

The study was internally funded. The authors reported having no conflicts of interest.

WASHINGTON – Although severe, community-acquired sepsis in previously healthy U.S. adults is relatively uncommon, it occurs often enough to strike about 40,000 people annually, and when previously healthy people are hospitalized for severe sepsis, their rate of in-hospital mortality was double the rate in people with one or more comorbidities who have severe, community-acquired sepsis, based on a review of almost 7 million Americans hospitalized for sepsis.

The findings “underscore the importance of improving public awareness of sepsis and emphasizing early sepsis recognition and treatment in all patients,” including those without comorbidities, Chanu Rhee, MD, said at an annual scientific meeting on infectious diseases. He hypothesized that the increased sepsis mortality among previously healthy patients may have stemmed from factors such as delayed sepsis recognition resulting in hospitalization at a more advanced stage and less aggressive management.

In addition, “the findings provide context for high-profile reports about sepsis death in previously healthy people,” said Dr. Rhee, an infectious diseases and critical care physician at Brigham and Women’s Hospital in Boston. Dr. Rhee and associates found that, among patients hospitalized with what the researchers defined as “community-acquired” sepsis, 3% were judged previously healthy by having no identified major or minor comorbidity or pregnancy at the time of hospitalization, a percentage that – while small – still translates into roughly 40,000 such cases annually in the United States. That helps explain why every so often a headline appears about a famous person who died suddenly and unexpectedly from sepsis, he noted.

The study used data collected on hospitalized U.S. patients in the Cerner Health Facts, HCA Healthcare, and Institute for Health Metrics and Evaluation databases, which included about 6.7 million people total including 337,983 identified as having community-acquired sepsis, defined as patients who met the criteria for adult sepsis advanced by the Centers for Disease Control and Prevention within 2 days of their hospital admission. The researchers looked further into the hospital records of these patients and divided them into patients with one or more major comorbidities (96% of the cohort), patients who were pregnant or had a “minor” comorbidity such as a lipid disorder, benign neoplasm, or obesity (1% of the study group), or those with no chronic comorbidity (3%; the subgroup the researchers deemed previously healthy).

In a multivariate analysis that adjusted for patients’ age, sex, race, infection site, and illness severity at the time of hospital admission the researchers found that the rate of in-hospital death among the previously healthy patients was exactly twice the rate of those who had at least one major chronic comorbidity, Dr. Rhee reported. Differences in the treatment received by the previously-healthy patients or in their medical status compared with patients with a major comorbidity suggested that the previously health patients were sicker. They had a higher rate of mechanical ventilation, 30%, compared with about 18% for those with a comorbidity; a higher rate of acute kidney injury, about 43% in those previously healthy and 28% in those with a comorbidity; and a higher percentage had an elevated lactate level, about 41% among the previously healthy patients and about 22% among those with a comorbidity.

[email protected]

SOURCE: Alrawashdeh M et al. Open Forum Infect Dis. 2019 Oct 23;6. Abstract 891.

WASHINGTON – Although severe, community-acquired sepsis in previously healthy U.S. adults is relatively uncommon, it occurs often enough to strike about 40,000 people annually, and when previously healthy people are hospitalized for severe sepsis, their rate of in-hospital mortality was double the rate in people with one or more comorbidities who have severe, community-acquired sepsis, based on a review of almost 7 million Americans hospitalized for sepsis.

The findings “underscore the importance of improving public awareness of sepsis and emphasizing early sepsis recognition and treatment in all patients,” including those without comorbidities, Chanu Rhee, MD, said at an annual scientific meeting on infectious diseases. He hypothesized that the increased sepsis mortality among previously healthy patients may have stemmed from factors such as delayed sepsis recognition resulting in hospitalization at a more advanced stage and less aggressive management.

In addition, “the findings provide context for high-profile reports about sepsis death in previously healthy people,” said Dr. Rhee, an infectious diseases and critical care physician at Brigham and Women’s Hospital in Boston. Dr. Rhee and associates found that, among patients hospitalized with what the researchers defined as “community-acquired” sepsis, 3% were judged previously healthy by having no identified major or minor comorbidity or pregnancy at the time of hospitalization, a percentage that – while small – still translates into roughly 40,000 such cases annually in the United States. That helps explain why every so often a headline appears about a famous person who died suddenly and unexpectedly from sepsis, he noted.

The study used data collected on hospitalized U.S. patients in the Cerner Health Facts, HCA Healthcare, and Institute for Health Metrics and Evaluation databases, which included about 6.7 million people total including 337,983 identified as having community-acquired sepsis, defined as patients who met the criteria for adult sepsis advanced by the Centers for Disease Control and Prevention within 2 days of their hospital admission. The researchers looked further into the hospital records of these patients and divided them into patients with one or more major comorbidities (96% of the cohort), patients who were pregnant or had a “minor” comorbidity such as a lipid disorder, benign neoplasm, or obesity (1% of the study group), or those with no chronic comorbidity (3%; the subgroup the researchers deemed previously healthy).

In a multivariate analysis that adjusted for patients’ age, sex, race, infection site, and illness severity at the time of hospital admission the researchers found that the rate of in-hospital death among the previously healthy patients was exactly twice the rate of those who had at least one major chronic comorbidity, Dr. Rhee reported. Differences in the treatment received by the previously-healthy patients or in their medical status compared with patients with a major comorbidity suggested that the previously health patients were sicker. They had a higher rate of mechanical ventilation, 30%, compared with about 18% for those with a comorbidity; a higher rate of acute kidney injury, about 43% in those previously healthy and 28% in those with a comorbidity; and a higher percentage had an elevated lactate level, about 41% among the previously healthy patients and about 22% among those with a comorbidity.

[email protected]

SOURCE: Alrawashdeh M et al. Open Forum Infect Dis. 2019 Oct 23;6. Abstract 891.

WASHINGTON – Although severe, community-acquired sepsis in previously healthy U.S. adults is relatively uncommon, it occurs often enough to strike about 40,000 people annually, and when previously healthy people are hospitalized for severe sepsis, their rate of in-hospital mortality was double the rate in people with one or more comorbidities who have severe, community-acquired sepsis, based on a review of almost 7 million Americans hospitalized for sepsis.

The findings “underscore the importance of improving public awareness of sepsis and emphasizing early sepsis recognition and treatment in all patients,” including those without comorbidities, Chanu Rhee, MD, said at an annual scientific meeting on infectious diseases. He hypothesized that the increased sepsis mortality among previously healthy patients may have stemmed from factors such as delayed sepsis recognition resulting in hospitalization at a more advanced stage and less aggressive management.

In addition, “the findings provide context for high-profile reports about sepsis death in previously healthy people,” said Dr. Rhee, an infectious diseases and critical care physician at Brigham and Women’s Hospital in Boston. Dr. Rhee and associates found that, among patients hospitalized with what the researchers defined as “community-acquired” sepsis, 3% were judged previously healthy by having no identified major or minor comorbidity or pregnancy at the time of hospitalization, a percentage that – while small – still translates into roughly 40,000 such cases annually in the United States. That helps explain why every so often a headline appears about a famous person who died suddenly and unexpectedly from sepsis, he noted.

The study used data collected on hospitalized U.S. patients in the Cerner Health Facts, HCA Healthcare, and Institute for Health Metrics and Evaluation databases, which included about 6.7 million people total including 337,983 identified as having community-acquired sepsis, defined as patients who met the criteria for adult sepsis advanced by the Centers for Disease Control and Prevention within 2 days of their hospital admission. The researchers looked further into the hospital records of these patients and divided them into patients with one or more major comorbidities (96% of the cohort), patients who were pregnant or had a “minor” comorbidity such as a lipid disorder, benign neoplasm, or obesity (1% of the study group), or those with no chronic comorbidity (3%; the subgroup the researchers deemed previously healthy).

In a multivariate analysis that adjusted for patients’ age, sex, race, infection site, and illness severity at the time of hospital admission the researchers found that the rate of in-hospital death among the previously healthy patients was exactly twice the rate of those who had at least one major chronic comorbidity, Dr. Rhee reported. Differences in the treatment received by the previously-healthy patients or in their medical status compared with patients with a major comorbidity suggested that the previously health patients were sicker. They had a higher rate of mechanical ventilation, 30%, compared with about 18% for those with a comorbidity; a higher rate of acute kidney injury, about 43% in those previously healthy and 28% in those with a comorbidity; and a higher percentage had an elevated lactate level, about 41% among the previously healthy patients and about 22% among those with a comorbidity.

[email protected]

SOURCE: Alrawashdeh M et al. Open Forum Infect Dis. 2019 Oct 23;6. Abstract 891.

The annual Skin Disease Education Foundation’s Las Vegas Dermatology Seminar gets underway Thursday and will feature presentations on topics ranging from updates on acne, hyperhidrosis, and rosacea, to pigmentation disorders and connective tissue disease. The annual Psoriasis Forum at the meeting will feature talks on tumor necrosis factor inhibitors and interleukin-17 inhibitors, as well as presentations on phototherapy, emerging treatments, and IL-12/23 and IL-23 inhibitors. The Atopic Dermatology Forum will address new horizons in treatment, pediatric inflammatory disease, and the pathophysiology of atopic dermatitis.

The meeting wraps up on Saturday, with a slate of aesthetic dermatology presentations, kicking off with “Assessment of the Aging Face” and ending with “An Overview of Tissue-Tightening Devices.”

New this year is the Cutaneous Malignancies Forum, which is being held today, one day before the regular Las Vegas Dermatology Seminar program begins. With a focus on contemporary issues in effective diagnosis and treatment of cutaneous malignancies, the forum is cochaired by Sancy Leachman, MD, PhD, professor and chair of the department of dermatology, and the John D. Gray endowed chair in melanoma research, at Oregon Health & Science Center, Portland, and Mohammed Kashani-Sabet, MD, director of the Center for Melanoma Research and Treatment, at the California Pacific Medical Research Institute, San Francisco. The forum will feature four sessions: melanoma, keratinocyte carcinomas, cutaneous T-cell lymphoma, and Merkel cell carcinoma.

SDEF and this news organization are owned by the same parent company. For full coverage, go to www.mdedge.com/dermatology.
 

[email protected]

The annual Skin Disease Education Foundation’s Las Vegas Dermatology Seminar gets underway Thursday and will feature presentations on topics ranging from updates on acne, hyperhidrosis, and rosacea, to pigmentation disorders and connective tissue disease. The annual Psoriasis Forum at the meeting will feature talks on tumor necrosis factor inhibitors and interleukin-17 inhibitors, as well as presentations on phototherapy, emerging treatments, and IL-12/23 and IL-23 inhibitors. The Atopic Dermatology Forum will address new horizons in treatment, pediatric inflammatory disease, and the pathophysiology of atopic dermatitis.

The meeting wraps up on Saturday, with a slate of aesthetic dermatology presentations, kicking off with “Assessment of the Aging Face” and ending with “An Overview of Tissue-Tightening Devices.”

New this year is the Cutaneous Malignancies Forum, which is being held today, one day before the regular Las Vegas Dermatology Seminar program begins. With a focus on contemporary issues in effective diagnosis and treatment of cutaneous malignancies, the forum is cochaired by Sancy Leachman, MD, PhD, professor and chair of the department of dermatology, and the John D. Gray endowed chair in melanoma research, at Oregon Health & Science Center, Portland, and Mohammed Kashani-Sabet, MD, director of the Center for Melanoma Research and Treatment, at the California Pacific Medical Research Institute, San Francisco. The forum will feature four sessions: melanoma, keratinocyte carcinomas, cutaneous T-cell lymphoma, and Merkel cell carcinoma.

SDEF and this news organization are owned by the same parent company. For full coverage, go to www.mdedge.com/dermatology.
 

[email protected]

The annual Skin Disease Education Foundation’s Las Vegas Dermatology Seminar gets underway Thursday and will feature presentations on topics ranging from updates on acne, hyperhidrosis, and rosacea, to pigmentation disorders and connective tissue disease. The annual Psoriasis Forum at the meeting will feature talks on tumor necrosis factor inhibitors and interleukin-17 inhibitors, as well as presentations on phototherapy, emerging treatments, and IL-12/23 and IL-23 inhibitors. The Atopic Dermatology Forum will address new horizons in treatment, pediatric inflammatory disease, and the pathophysiology of atopic dermatitis.

The meeting wraps up on Saturday, with a slate of aesthetic dermatology presentations, kicking off with “Assessment of the Aging Face” and ending with “An Overview of Tissue-Tightening Devices.”

New this year is the Cutaneous Malignancies Forum, which is being held today, one day before the regular Las Vegas Dermatology Seminar program begins. With a focus on contemporary issues in effective diagnosis and treatment of cutaneous malignancies, the forum is cochaired by Sancy Leachman, MD, PhD, professor and chair of the department of dermatology, and the John D. Gray endowed chair in melanoma research, at Oregon Health & Science Center, Portland, and Mohammed Kashani-Sabet, MD, director of the Center for Melanoma Research and Treatment, at the California Pacific Medical Research Institute, San Francisco. The forum will feature four sessions: melanoma, keratinocyte carcinomas, cutaneous T-cell lymphoma, and Merkel cell carcinoma.

SDEF and this news organization are owned by the same parent company. For full coverage, go to www.mdedge.com/dermatology.
 

[email protected]

The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.

The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.

Background

The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. ¹

When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.^2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. ^2-5

Identified Needs

Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.⁶ Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.

Perceived Government Indifference

The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.⁷ A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.⁸ These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.

Access to Medical Care

Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.⁹ Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.

Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.¹⁰ The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.¹¹

Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.^10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.^2,3

Lack of Health Care and Radicalism

It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.^12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.¹⁵ In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.¹⁶ It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.

In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.¹⁷ Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.^17,18

Proposed Solutions, A Beginning

A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.¹⁷

In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.¹⁹ The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.

Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.

The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.

Disaster Response

Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.

Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.²⁰ Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.²¹ These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.

This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.

Underserved Communities

Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.¹⁷

The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.

Conclusion

This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.

The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.

The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.

Background

The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. ¹

When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.^2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. ^2-5

Identified Needs

Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.⁶ Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.

Perceived Government Indifference

The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.⁷ A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.⁸ These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.

Access to Medical Care

Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.⁹ Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.

Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.¹⁰ The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.¹¹

Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.^10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.^2,3

Lack of Health Care and Radicalism

It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.^12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.¹⁵ In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.¹⁶ It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.

In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.¹⁷ Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.^17,18

Proposed Solutions, A Beginning

A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.¹⁷

In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.¹⁹ The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.

Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.

The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.

Disaster Response

Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.

Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.²⁰ Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.²¹ These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.

This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.

Underserved Communities

Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.¹⁷

The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.

Conclusion

This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.

The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.

The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.

Background

The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. ¹

When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.^2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. ^2-5

Identified Needs

Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.⁶ Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.

Perceived Government Indifference

The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.⁷ A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.⁸ These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.

Access to Medical Care

Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.⁹ Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.

Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.¹⁰ The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.¹¹

Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.^10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.^2,3

Lack of Health Care and Radicalism

It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.^12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.¹⁵ In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.¹⁶ It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.

In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.¹⁷ Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.^17,18

Proposed Solutions, A Beginning

A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.¹⁷

In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.¹⁹ The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.

Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.

The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.

Disaster Response

Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.

Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.²⁰ Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.²¹ These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.

This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.

Underserved Communities

Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.¹⁷

The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.

Conclusion

This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.

Treating Clostridioides difficile infection with fecal microbiota transplantation is associated with a lower risk of bloodstream infection and recurrence than treatment with antibiotics, new research has found.

A paper published in Annals of Internal Medicine presents outcomes of a prospective cohort study in 290 inpatients with recurrent C. difficile infection, 109 of whom were treated with fecal microbiota transplantation (FMT); the remainder were treated with antibiotics including metronidazole, vancomycin, and fidaxomicin.

While the FMT group had a higher mean number of previous C. difficile infections than the antibiotics group (2.82 vs. 1.23, respectively), a sustained cure was achieved in 97% of the FMT group, compared with 38% in the antibiotics group.

Blood cultures were done if patients developed a temperature above 30° C or showed symptoms that might be attributable to sepsis. Bloodstream infections were diagnosed in 5% (5 patients) of those treated with FMT, and 22% (40 patients) in the antibiotics group.

The patients in the FMT group with bloodstream infections all had bacterial infections – one of which was polymicrobial – and there were no cases of fungal bloodstream infections. In the antibiotics group, 28 patients (15%) had bacterial bloodstream infections – 11 of which were polymicrobial – and 12 (7%) had fungal bloodstream infections.

Bloodstream infections were particularly evident among the 11 patients whose C. difficile infection was treated with fidaxomicin, 4 of whom developed a bloodstream infection.

Overall, 27% of patients died during the 90-day follow-up, with 7% dying because of bloodstream infections, all of whom were in the antibiotic-treated cohort. Three patients in the FMT group died because of overwhelming C. difficile infection, compared with 12 in the antibiotic cohort.

Nearly three-quarters of deaths occurred within 30 days of the end of treatment; 5 of these deaths were in the FMT group, and 53 were in the antibiotics group.

“These findings suggest that the longer 90-day [overall survival] of patients in the FMT group is attributable to cure of [C. difficile infection] leading to an improvement in clinical condition,” wrote Gianluca Ianiro, MD, from the Catholic University of the Sacred Heart in Rome, and coauthors.

The 90-day overall survival rate was 92% in the FMT group and 61% in the antibiotic group. Patients treated with FMT also showed significantly shorter mean duration of hospital stay at 13.3 days, compared with 29.7 days in patients treated with antibiotics.

The authors noted the results should be interpreted with caution because of baseline differences between the two groups that were not entirely accounted for by using propensity matching. However, even in the propensity-matched cohort of 57 patients from each group, there was still a significantly higher overall survival at 90 days among patients treated with FMT.

One author declared grants from the pharmaceutical sector outside the submitted work. No funding or other conflicts of interest were reported.

SOURCE: Ianiro G et al. Ann Intern Med. 2019 Nov 4. doi: 10.7326/M18-3635.

Treating Clostridioides difficile infection with fecal microbiota transplantation is associated with a lower risk of bloodstream infection and recurrence than treatment with antibiotics, new research has found.

A paper published in Annals of Internal Medicine presents outcomes of a prospective cohort study in 290 inpatients with recurrent C. difficile infection, 109 of whom were treated with fecal microbiota transplantation (FMT); the remainder were treated with antibiotics including metronidazole, vancomycin, and fidaxomicin.

While the FMT group had a higher mean number of previous C. difficile infections than the antibiotics group (2.82 vs. 1.23, respectively), a sustained cure was achieved in 97% of the FMT group, compared with 38% in the antibiotics group.

Blood cultures were done if patients developed a temperature above 30° C or showed symptoms that might be attributable to sepsis. Bloodstream infections were diagnosed in 5% (5 patients) of those treated with FMT, and 22% (40 patients) in the antibiotics group.

The patients in the FMT group with bloodstream infections all had bacterial infections – one of which was polymicrobial – and there were no cases of fungal bloodstream infections. In the antibiotics group, 28 patients (15%) had bacterial bloodstream infections – 11 of which were polymicrobial – and 12 (7%) had fungal bloodstream infections.

Bloodstream infections were particularly evident among the 11 patients whose C. difficile infection was treated with fidaxomicin, 4 of whom developed a bloodstream infection.

Overall, 27% of patients died during the 90-day follow-up, with 7% dying because of bloodstream infections, all of whom were in the antibiotic-treated cohort. Three patients in the FMT group died because of overwhelming C. difficile infection, compared with 12 in the antibiotic cohort.

Nearly three-quarters of deaths occurred within 30 days of the end of treatment; 5 of these deaths were in the FMT group, and 53 were in the antibiotics group.

“These findings suggest that the longer 90-day [overall survival] of patients in the FMT group is attributable to cure of [C. difficile infection] leading to an improvement in clinical condition,” wrote Gianluca Ianiro, MD, from the Catholic University of the Sacred Heart in Rome, and coauthors.

The 90-day overall survival rate was 92% in the FMT group and 61% in the antibiotic group. Patients treated with FMT also showed significantly shorter mean duration of hospital stay at 13.3 days, compared with 29.7 days in patients treated with antibiotics.

The authors noted the results should be interpreted with caution because of baseline differences between the two groups that were not entirely accounted for by using propensity matching. However, even in the propensity-matched cohort of 57 patients from each group, there was still a significantly higher overall survival at 90 days among patients treated with FMT.

One author declared grants from the pharmaceutical sector outside the submitted work. No funding or other conflicts of interest were reported.

SOURCE: Ianiro G et al. Ann Intern Med. 2019 Nov 4. doi: 10.7326/M18-3635.

Treating Clostridioides difficile infection with fecal microbiota transplantation is associated with a lower risk of bloodstream infection and recurrence than treatment with antibiotics, new research has found.

A paper published in Annals of Internal Medicine presents outcomes of a prospective cohort study in 290 inpatients with recurrent C. difficile infection, 109 of whom were treated with fecal microbiota transplantation (FMT); the remainder were treated with antibiotics including metronidazole, vancomycin, and fidaxomicin.

While the FMT group had a higher mean number of previous C. difficile infections than the antibiotics group (2.82 vs. 1.23, respectively), a sustained cure was achieved in 97% of the FMT group, compared with 38% in the antibiotics group.

Blood cultures were done if patients developed a temperature above 30° C or showed symptoms that might be attributable to sepsis. Bloodstream infections were diagnosed in 5% (5 patients) of those treated with FMT, and 22% (40 patients) in the antibiotics group.

The patients in the FMT group with bloodstream infections all had bacterial infections – one of which was polymicrobial – and there were no cases of fungal bloodstream infections. In the antibiotics group, 28 patients (15%) had bacterial bloodstream infections – 11 of which were polymicrobial – and 12 (7%) had fungal bloodstream infections.

Bloodstream infections were particularly evident among the 11 patients whose C. difficile infection was treated with fidaxomicin, 4 of whom developed a bloodstream infection.

Overall, 27% of patients died during the 90-day follow-up, with 7% dying because of bloodstream infections, all of whom were in the antibiotic-treated cohort. Three patients in the FMT group died because of overwhelming C. difficile infection, compared with 12 in the antibiotic cohort.

Nearly three-quarters of deaths occurred within 30 days of the end of treatment; 5 of these deaths were in the FMT group, and 53 were in the antibiotics group.

“These findings suggest that the longer 90-day [overall survival] of patients in the FMT group is attributable to cure of [C. difficile infection] leading to an improvement in clinical condition,” wrote Gianluca Ianiro, MD, from the Catholic University of the Sacred Heart in Rome, and coauthors.

The 90-day overall survival rate was 92% in the FMT group and 61% in the antibiotic group. Patients treated with FMT also showed significantly shorter mean duration of hospital stay at 13.3 days, compared with 29.7 days in patients treated with antibiotics.

The authors noted the results should be interpreted with caution because of baseline differences between the two groups that were not entirely accounted for by using propensity matching. However, even in the propensity-matched cohort of 57 patients from each group, there was still a significantly higher overall survival at 90 days among patients treated with FMT.

One author declared grants from the pharmaceutical sector outside the submitted work. No funding or other conflicts of interest were reported.

SOURCE: Ianiro G et al. Ann Intern Med. 2019 Nov 4. doi: 10.7326/M18-3635.

Since 2005 the government website Hospital Compare has publicly reported quality data on hospitals, with periodic updates of their performance, including specific measures of quality. But how accurately do the ratings reflect a hospital’s actual quality of care, and what do the ratings mean for hospitalists?

Hospital Compare provides searchable, comparable information to consumers on reported quality of care data submitted by more than 4,000 Medicare-certified hospitals, along with Veterans Administration and military health system hospitals. It is designed to allow consumers to select hospitals and directly compare their mortality, complication, infection, and other performance measures on conditions such as heart attacks, heart failure, pneumonia, and surgical outcomes.

The Overall Hospital Quality Star Ratings, which began in 2016, combine data from more than 50 quality measures publicly reported on Hospital Compare into an overall rating of one to five stars for each hospital. These ratings are designed to enhance and supplement existing quality measures with a more “customer-centric” measure that makes it easier for consumers to act on the information. Obviously, this would be helpful to consumers who feel overwhelmed by the volume of data on the Hospital Compare website, and by the complexity of some of the measures.

A posted call in spring 2019 by CMS for public comment on possible methodological changes to the Overall Hospital Quality Star Ratings received more than 800 comments from 150 different organizations. And this past summer, the Centers for Medicare & Medicaid Services decided to delay posting the refreshed Star Ratings in its Hospital Compare data preview reports for July 2019. The agency says it intends to release the updated information in early 2020. Meanwhile, the reported data – particularly the overall star ratings – continue to generate controversy for the hospital field.
 

Hospitalists’ critical role

Hospitalists are not rated individually on Hospital Compare, but they play important roles in the quality of care their hospital provides – and thus ultimately the hospital’s publicly reported rankings. Hospitalists typically are not specifically incentivized or penalized for their hospital’s performance, but this does happen in some cases.

“Hospital administrators absolutely take note of their hospital’s star ratings. These are the people hospitalists work for, and this is definitely top of their minds,” said Kate Goodrich, MD, MHS, director of the Center for Clinical Standards and Quality at CMS. “I recently spoke at an SHM annual conference and every question I was asked was about hospital ratings and the star system,” noted Dr. Goodrich, herself a practicing hospitalist at George Washington University Medical Center in Washington.

The government’s aim for Hospital Compare is to give consumers easy-to-understand indicators of the quality of care provided by hospitals, especially where they might have a choice of hospitals, such as for an elective surgery. Making that information public is also viewed as a motivator to help drive improvements in hospital performance, Dr. Goodrich said.

“In terms of what we measure, we try to make sure it’s important to patients and to clinicians. We have frontline practicing physicians, patients, and families advising us, along with methodologists and PhD researchers. These stakeholders tell us what is important to measure and why,” she said. “Hospitals and all health providers need more actionable and timely data to improve their quality of care, especially if they want to participate in accountable care organizations. And we need to make the information easy to understand.”

Dr. Goodrich sees two main themes in the public response to its request for comment. “People say the methodology we use to calculate star ratings is frustrating for hospitals, which have found it difficult to model their performance, predict their star ratings, or explain the discrepancies.” Hospitals taking care of sicker patients with lower socioeconomic status also say the ratings unfairly penalize them. “I work in a large urban hospital, and I understand this. They say we don’t take that sufficiently into account in the ratings,” she said.

“While our modeling shows that current ratings highly correlate with performance on individual measures, we have asked for comment on if and how we could adjust for socioeconomic factors. We are actively considering how to make changes to address these concerns,” Dr. Goodrich said.

In August 2019, CMS acknowledged that it plans to change the methodology used to calculate hospital star ratings in early 2021, but has not yet revealed specific details about the nature of the changes. The agency intends to propose the changes through the public rule-making process sometime in 2020.
 

Continuing controversy

The American Hospital Association – which has had strong concerns about the methodology and the usefulness of hospital star ratings – is pushing back on some of the changes to the system being considered by CMS. In its submitted comments, AHA supported only three of the 14 potential star ratings methodology changes being considered. AHA and the American Association of Medical Colleges, among others, have urged taking down the star ratings until major changes can be made.

“When the star ratings were first implemented, a lot of challenges became apparent right away,” said Akin Demehin, MPH, AHA’s director of quality policy. “We began to see that those hospitals that treat more complicated patients and poorer patients tended to perform more poorly on the ratings. So there was something wrong with the methodology. Then, starting in 2018, hospitals began seeing real shifts in their performance ratings when the underlying data hadn’t really changed.”

CMS uses a statistical approach called latent variable modeling. Its underlying assumption is that you can say something about a hospital’s underlying quality based on the data you already have, Mr. Demehin said, but noted “that can be a questionable assumption.” He also emphasized the need for ratings that compare hospitals that are similar in size and model to each other.

Suparna Dutta, MD, division chief, hospital medicine, Rush University, Chicago, said analyses done at Rush showed that the statistical model CMS used in calculating the star ratings was dynamically changing the weighting of certain measures in every release. “That meant one specific performance measure could play an outsized role in determining a final rating,” she said. In particular the methodology inadvertently penalized large hospitals, academic medical centers, and institutions that provide heroic care.

“We fundamentally believe that consumers should have meaningful information about hospital quality,” said Nancy Foster, AHA’s vice president for quality and patient safety policy at AHA. “We understand the complexities of Hospital Compare and the challenges of getting simple information for consumers. To its credit, CMS is thinking about how to do that, and we support them in that effort.”
 

Getting a handle on quality

Hospitalists are responsible for ensuring that their hospitals excel in the care of patients, said Julius Yang, MD, hospitalist and director of quality at Beth Israel Deaconess Medical Center in Boston. That also requires keeping up on the primary public ways these issues are addressed through reporting of quality data and through reimbursement policy. “That should be part of our core competencies as hospitalists.”

Some of the measures on Hospital Compare don’t overlap much with the work of hospitalists, he noted. But for others, such as for pneumonia, COPD, and care of patients with stroke, or for mortality and 30-day readmissions rates, “we are involved, even if not directly, and certainly responsible for contributing to the outcomes and the opportunity to add value,” he said.

“When it comes to 30-day readmission rates, do we really understand the risk factors for readmissions and the barriers to patients remaining in the community after their hospital stay? Are our patients stable enough to be discharged, and have we worked with the care coordination team to make sure they have the resources they need? And have we communicated adequately with the outpatient doctor? All of these things are within the wheelhouse of the hospitalist,” Dr. Yang said. “Let’s accept that the readmissions rate, for example, is not a perfect measure of quality. But as an imperfect measure, it can point us in the right direction.”

Jose Figueroa, MD, MPH, hospitalist and assistant professor at Harvard Medical School, has been studying for his health system the impact of hospital penalties such as the Hospital Readmissions Reduction Program on health equity. In general, hospitalists play an important role in dictating processes of care and serving on quality-oriented committees across multiple realms of the hospital, he said.

“What’s hard from the hospitalist’s perspective is that there don’t seem to be simple solutions to move the dial on many of these measures,” Dr. Figueroa said. “If the hospital is at three stars, can we say, okay, if we do X, Y, and Z, then our hospital will move from three to five stars? Some of these measures are so broad and not in our purview. Which ones apply to me as a hospitalist and my care processes?”

Dr. Dutta sits on the SHM Policy Committee, which has been working to bring these issues to the attention of frontline hospitalists. “Hospitalists are always going to be aligned with their hospital’s priorities. We’re in it to provide high-quality care, but there’s no magic way to do that,” she said.

Hospital Compare measures sometimes end up in hospitalist incentives plans – for example, the readmission penalty rates – even though that is a fairly arbitrary measure and hard to pin to one doctor, Dr. Dutta explained. “If you look at the evidence regarding these metrics, there are not a lot of data to show that the metrics lead to what we really want, which is better care for patients.”

A recent study in the British Medical Journal, for example, examined the association between the penalties on hospitals in the Hospital Acquired Condition Reduction Program and clinical outcome.¹ The researchers concluded that the penalties were not associated with significant change or found to drive meaningful clinical improvement.
 

How can hospitalists engage with Compare?

Dr. Goodrich refers hospitalists seeking quality resources to their local quality improvement organizations (QIO) and to Hospital Improvement Innovation Networks at the regional, state, national, or hospital system level.

One helpful thing that any group of hospitalists could do, added Dr. Figueroa, is to examine the measures closely and determine which ones they think they can influence. “Then look for the hospitals that resemble ours and care for similar patients, based on the demographics. We can then say: ‘Okay, that’s a fair comparison. This can be a benchmark with our peers,’” he said. Then it’s important to ask how your hospital is doing over time on these measures, and use that to prioritize.

“You also have to appreciate that these are broad quality measures, and to impact them you have to do broad quality improvement efforts. Another piece of this is getting good at collecting and analyzing data internally in a timely fashion. You don’t want to wait 2-3 years to find out in Hospital Compare that you’re not performing well. You care about the care you provided today, not 2 or 3 years ago. Without this internal check, it’s impossible to know what to invest in – and to see if things you do are having an impact,” Dr. Figueroa said.

“As physician leaders, this is a real opportunity for us to trigger a conversation with our hospital’s administration around what we went into medicine for in the first place – to improve our patients’ care,” said Dr. Goodrich. She said Hospital Compare is one tool for sparking systemic quality improvement across the hospital – which is an important part of the hospitalist’s job. “If you want to be a bigger star within your hospital, show that level of commitment. It likely would be welcomed by your hospital.”
 

Reference

1. Sankaran R et al. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. BMJ. 2019 Jul 3 doi: 10.1136/bmj.l4109.

Since 2005 the government website Hospital Compare has publicly reported quality data on hospitals, with periodic updates of their performance, including specific measures of quality. But how accurately do the ratings reflect a hospital’s actual quality of care, and what do the ratings mean for hospitalists?

Hospital Compare provides searchable, comparable information to consumers on reported quality of care data submitted by more than 4,000 Medicare-certified hospitals, along with Veterans Administration and military health system hospitals. It is designed to allow consumers to select hospitals and directly compare their mortality, complication, infection, and other performance measures on conditions such as heart attacks, heart failure, pneumonia, and surgical outcomes.

The Overall Hospital Quality Star Ratings, which began in 2016, combine data from more than 50 quality measures publicly reported on Hospital Compare into an overall rating of one to five stars for each hospital. These ratings are designed to enhance and supplement existing quality measures with a more “customer-centric” measure that makes it easier for consumers to act on the information. Obviously, this would be helpful to consumers who feel overwhelmed by the volume of data on the Hospital Compare website, and by the complexity of some of the measures.

A posted call in spring 2019 by CMS for public comment on possible methodological changes to the Overall Hospital Quality Star Ratings received more than 800 comments from 150 different organizations. And this past summer, the Centers for Medicare & Medicaid Services decided to delay posting the refreshed Star Ratings in its Hospital Compare data preview reports for July 2019. The agency says it intends to release the updated information in early 2020. Meanwhile, the reported data – particularly the overall star ratings – continue to generate controversy for the hospital field.
 

Hospitalists’ critical role

Hospitalists are not rated individually on Hospital Compare, but they play important roles in the quality of care their hospital provides – and thus ultimately the hospital’s publicly reported rankings. Hospitalists typically are not specifically incentivized or penalized for their hospital’s performance, but this does happen in some cases.

“Hospital administrators absolutely take note of their hospital’s star ratings. These are the people hospitalists work for, and this is definitely top of their minds,” said Kate Goodrich, MD, MHS, director of the Center for Clinical Standards and Quality at CMS. “I recently spoke at an SHM annual conference and every question I was asked was about hospital ratings and the star system,” noted Dr. Goodrich, herself a practicing hospitalist at George Washington University Medical Center in Washington.

The government’s aim for Hospital Compare is to give consumers easy-to-understand indicators of the quality of care provided by hospitals, especially where they might have a choice of hospitals, such as for an elective surgery. Making that information public is also viewed as a motivator to help drive improvements in hospital performance, Dr. Goodrich said.

“In terms of what we measure, we try to make sure it’s important to patients and to clinicians. We have frontline practicing physicians, patients, and families advising us, along with methodologists and PhD researchers. These stakeholders tell us what is important to measure and why,” she said. “Hospitals and all health providers need more actionable and timely data to improve their quality of care, especially if they want to participate in accountable care organizations. And we need to make the information easy to understand.”

Dr. Goodrich sees two main themes in the public response to its request for comment. “People say the methodology we use to calculate star ratings is frustrating for hospitals, which have found it difficult to model their performance, predict their star ratings, or explain the discrepancies.” Hospitals taking care of sicker patients with lower socioeconomic status also say the ratings unfairly penalize them. “I work in a large urban hospital, and I understand this. They say we don’t take that sufficiently into account in the ratings,” she said.

“While our modeling shows that current ratings highly correlate with performance on individual measures, we have asked for comment on if and how we could adjust for socioeconomic factors. We are actively considering how to make changes to address these concerns,” Dr. Goodrich said.

In August 2019, CMS acknowledged that it plans to change the methodology used to calculate hospital star ratings in early 2021, but has not yet revealed specific details about the nature of the changes. The agency intends to propose the changes through the public rule-making process sometime in 2020.
 

Continuing controversy

The American Hospital Association – which has had strong concerns about the methodology and the usefulness of hospital star ratings – is pushing back on some of the changes to the system being considered by CMS. In its submitted comments, AHA supported only three of the 14 potential star ratings methodology changes being considered. AHA and the American Association of Medical Colleges, among others, have urged taking down the star ratings until major changes can be made.

“When the star ratings were first implemented, a lot of challenges became apparent right away,” said Akin Demehin, MPH, AHA’s director of quality policy. “We began to see that those hospitals that treat more complicated patients and poorer patients tended to perform more poorly on the ratings. So there was something wrong with the methodology. Then, starting in 2018, hospitals began seeing real shifts in their performance ratings when the underlying data hadn’t really changed.”

CMS uses a statistical approach called latent variable modeling. Its underlying assumption is that you can say something about a hospital’s underlying quality based on the data you already have, Mr. Demehin said, but noted “that can be a questionable assumption.” He also emphasized the need for ratings that compare hospitals that are similar in size and model to each other.

Suparna Dutta, MD, division chief, hospital medicine, Rush University, Chicago, said analyses done at Rush showed that the statistical model CMS used in calculating the star ratings was dynamically changing the weighting of certain measures in every release. “That meant one specific performance measure could play an outsized role in determining a final rating,” she said. In particular the methodology inadvertently penalized large hospitals, academic medical centers, and institutions that provide heroic care.

“We fundamentally believe that consumers should have meaningful information about hospital quality,” said Nancy Foster, AHA’s vice president for quality and patient safety policy at AHA. “We understand the complexities of Hospital Compare and the challenges of getting simple information for consumers. To its credit, CMS is thinking about how to do that, and we support them in that effort.”
 

Getting a handle on quality

Hospitalists are responsible for ensuring that their hospitals excel in the care of patients, said Julius Yang, MD, hospitalist and director of quality at Beth Israel Deaconess Medical Center in Boston. That also requires keeping up on the primary public ways these issues are addressed through reporting of quality data and through reimbursement policy. “That should be part of our core competencies as hospitalists.”

Some of the measures on Hospital Compare don’t overlap much with the work of hospitalists, he noted. But for others, such as for pneumonia, COPD, and care of patients with stroke, or for mortality and 30-day readmissions rates, “we are involved, even if not directly, and certainly responsible for contributing to the outcomes and the opportunity to add value,” he said.

“When it comes to 30-day readmission rates, do we really understand the risk factors for readmissions and the barriers to patients remaining in the community after their hospital stay? Are our patients stable enough to be discharged, and have we worked with the care coordination team to make sure they have the resources they need? And have we communicated adequately with the outpatient doctor? All of these things are within the wheelhouse of the hospitalist,” Dr. Yang said. “Let’s accept that the readmissions rate, for example, is not a perfect measure of quality. But as an imperfect measure, it can point us in the right direction.”

Jose Figueroa, MD, MPH, hospitalist and assistant professor at Harvard Medical School, has been studying for his health system the impact of hospital penalties such as the Hospital Readmissions Reduction Program on health equity. In general, hospitalists play an important role in dictating processes of care and serving on quality-oriented committees across multiple realms of the hospital, he said.

“What’s hard from the hospitalist’s perspective is that there don’t seem to be simple solutions to move the dial on many of these measures,” Dr. Figueroa said. “If the hospital is at three stars, can we say, okay, if we do X, Y, and Z, then our hospital will move from three to five stars? Some of these measures are so broad and not in our purview. Which ones apply to me as a hospitalist and my care processes?”

Dr. Dutta sits on the SHM Policy Committee, which has been working to bring these issues to the attention of frontline hospitalists. “Hospitalists are always going to be aligned with their hospital’s priorities. We’re in it to provide high-quality care, but there’s no magic way to do that,” she said.

Hospital Compare measures sometimes end up in hospitalist incentives plans – for example, the readmission penalty rates – even though that is a fairly arbitrary measure and hard to pin to one doctor, Dr. Dutta explained. “If you look at the evidence regarding these metrics, there are not a lot of data to show that the metrics lead to what we really want, which is better care for patients.”

A recent study in the British Medical Journal, for example, examined the association between the penalties on hospitals in the Hospital Acquired Condition Reduction Program and clinical outcome.¹ The researchers concluded that the penalties were not associated with significant change or found to drive meaningful clinical improvement.
 

How can hospitalists engage with Compare?

Dr. Goodrich refers hospitalists seeking quality resources to their local quality improvement organizations (QIO) and to Hospital Improvement Innovation Networks at the regional, state, national, or hospital system level.

One helpful thing that any group of hospitalists could do, added Dr. Figueroa, is to examine the measures closely and determine which ones they think they can influence. “Then look for the hospitals that resemble ours and care for similar patients, based on the demographics. We can then say: ‘Okay, that’s a fair comparison. This can be a benchmark with our peers,’” he said. Then it’s important to ask how your hospital is doing over time on these measures, and use that to prioritize.

“You also have to appreciate that these are broad quality measures, and to impact them you have to do broad quality improvement efforts. Another piece of this is getting good at collecting and analyzing data internally in a timely fashion. You don’t want to wait 2-3 years to find out in Hospital Compare that you’re not performing well. You care about the care you provided today, not 2 or 3 years ago. Without this internal check, it’s impossible to know what to invest in – and to see if things you do are having an impact,” Dr. Figueroa said.

“As physician leaders, this is a real opportunity for us to trigger a conversation with our hospital’s administration around what we went into medicine for in the first place – to improve our patients’ care,” said Dr. Goodrich. She said Hospital Compare is one tool for sparking systemic quality improvement across the hospital – which is an important part of the hospitalist’s job. “If you want to be a bigger star within your hospital, show that level of commitment. It likely would be welcomed by your hospital.”
 

Reference

1. Sankaran R et al. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. BMJ. 2019 Jul 3 doi: 10.1136/bmj.l4109.

Since 2005 the government website Hospital Compare has publicly reported quality data on hospitals, with periodic updates of their performance, including specific measures of quality. But how accurately do the ratings reflect a hospital’s actual quality of care, and what do the ratings mean for hospitalists?

Hospital Compare provides searchable, comparable information to consumers on reported quality of care data submitted by more than 4,000 Medicare-certified hospitals, along with Veterans Administration and military health system hospitals. It is designed to allow consumers to select hospitals and directly compare their mortality, complication, infection, and other performance measures on conditions such as heart attacks, heart failure, pneumonia, and surgical outcomes.

The Overall Hospital Quality Star Ratings, which began in 2016, combine data from more than 50 quality measures publicly reported on Hospital Compare into an overall rating of one to five stars for each hospital. These ratings are designed to enhance and supplement existing quality measures with a more “customer-centric” measure that makes it easier for consumers to act on the information. Obviously, this would be helpful to consumers who feel overwhelmed by the volume of data on the Hospital Compare website, and by the complexity of some of the measures.

A posted call in spring 2019 by CMS for public comment on possible methodological changes to the Overall Hospital Quality Star Ratings received more than 800 comments from 150 different organizations. And this past summer, the Centers for Medicare & Medicaid Services decided to delay posting the refreshed Star Ratings in its Hospital Compare data preview reports for July 2019. The agency says it intends to release the updated information in early 2020. Meanwhile, the reported data – particularly the overall star ratings – continue to generate controversy for the hospital field.
 

Hospitalists’ critical role

Hospitalists are not rated individually on Hospital Compare, but they play important roles in the quality of care their hospital provides – and thus ultimately the hospital’s publicly reported rankings. Hospitalists typically are not specifically incentivized or penalized for their hospital’s performance, but this does happen in some cases.

“Hospital administrators absolutely take note of their hospital’s star ratings. These are the people hospitalists work for, and this is definitely top of their minds,” said Kate Goodrich, MD, MHS, director of the Center for Clinical Standards and Quality at CMS. “I recently spoke at an SHM annual conference and every question I was asked was about hospital ratings and the star system,” noted Dr. Goodrich, herself a practicing hospitalist at George Washington University Medical Center in Washington.

The government’s aim for Hospital Compare is to give consumers easy-to-understand indicators of the quality of care provided by hospitals, especially where they might have a choice of hospitals, such as for an elective surgery. Making that information public is also viewed as a motivator to help drive improvements in hospital performance, Dr. Goodrich said.

“In terms of what we measure, we try to make sure it’s important to patients and to clinicians. We have frontline practicing physicians, patients, and families advising us, along with methodologists and PhD researchers. These stakeholders tell us what is important to measure and why,” she said. “Hospitals and all health providers need more actionable and timely data to improve their quality of care, especially if they want to participate in accountable care organizations. And we need to make the information easy to understand.”

Dr. Goodrich sees two main themes in the public response to its request for comment. “People say the methodology we use to calculate star ratings is frustrating for hospitals, which have found it difficult to model their performance, predict their star ratings, or explain the discrepancies.” Hospitals taking care of sicker patients with lower socioeconomic status also say the ratings unfairly penalize them. “I work in a large urban hospital, and I understand this. They say we don’t take that sufficiently into account in the ratings,” she said.

“While our modeling shows that current ratings highly correlate with performance on individual measures, we have asked for comment on if and how we could adjust for socioeconomic factors. We are actively considering how to make changes to address these concerns,” Dr. Goodrich said.

In August 2019, CMS acknowledged that it plans to change the methodology used to calculate hospital star ratings in early 2021, but has not yet revealed specific details about the nature of the changes. The agency intends to propose the changes through the public rule-making process sometime in 2020.
 

Continuing controversy

The American Hospital Association – which has had strong concerns about the methodology and the usefulness of hospital star ratings – is pushing back on some of the changes to the system being considered by CMS. In its submitted comments, AHA supported only three of the 14 potential star ratings methodology changes being considered. AHA and the American Association of Medical Colleges, among others, have urged taking down the star ratings until major changes can be made.

“When the star ratings were first implemented, a lot of challenges became apparent right away,” said Akin Demehin, MPH, AHA’s director of quality policy. “We began to see that those hospitals that treat more complicated patients and poorer patients tended to perform more poorly on the ratings. So there was something wrong with the methodology. Then, starting in 2018, hospitals began seeing real shifts in their performance ratings when the underlying data hadn’t really changed.”

CMS uses a statistical approach called latent variable modeling. Its underlying assumption is that you can say something about a hospital’s underlying quality based on the data you already have, Mr. Demehin said, but noted “that can be a questionable assumption.” He also emphasized the need for ratings that compare hospitals that are similar in size and model to each other.

Suparna Dutta, MD, division chief, hospital medicine, Rush University, Chicago, said analyses done at Rush showed that the statistical model CMS used in calculating the star ratings was dynamically changing the weighting of certain measures in every release. “That meant one specific performance measure could play an outsized role in determining a final rating,” she said. In particular the methodology inadvertently penalized large hospitals, academic medical centers, and institutions that provide heroic care.

“We fundamentally believe that consumers should have meaningful information about hospital quality,” said Nancy Foster, AHA’s vice president for quality and patient safety policy at AHA. “We understand the complexities of Hospital Compare and the challenges of getting simple information for consumers. To its credit, CMS is thinking about how to do that, and we support them in that effort.”
 

Getting a handle on quality

Hospitalists are responsible for ensuring that their hospitals excel in the care of patients, said Julius Yang, MD, hospitalist and director of quality at Beth Israel Deaconess Medical Center in Boston. That also requires keeping up on the primary public ways these issues are addressed through reporting of quality data and through reimbursement policy. “That should be part of our core competencies as hospitalists.”

Some of the measures on Hospital Compare don’t overlap much with the work of hospitalists, he noted. But for others, such as for pneumonia, COPD, and care of patients with stroke, or for mortality and 30-day readmissions rates, “we are involved, even if not directly, and certainly responsible for contributing to the outcomes and the opportunity to add value,” he said.

“When it comes to 30-day readmission rates, do we really understand the risk factors for readmissions and the barriers to patients remaining in the community after their hospital stay? Are our patients stable enough to be discharged, and have we worked with the care coordination team to make sure they have the resources they need? And have we communicated adequately with the outpatient doctor? All of these things are within the wheelhouse of the hospitalist,” Dr. Yang said. “Let’s accept that the readmissions rate, for example, is not a perfect measure of quality. But as an imperfect measure, it can point us in the right direction.”

Jose Figueroa, MD, MPH, hospitalist and assistant professor at Harvard Medical School, has been studying for his health system the impact of hospital penalties such as the Hospital Readmissions Reduction Program on health equity. In general, hospitalists play an important role in dictating processes of care and serving on quality-oriented committees across multiple realms of the hospital, he said.

“What’s hard from the hospitalist’s perspective is that there don’t seem to be simple solutions to move the dial on many of these measures,” Dr. Figueroa said. “If the hospital is at three stars, can we say, okay, if we do X, Y, and Z, then our hospital will move from three to five stars? Some of these measures are so broad and not in our purview. Which ones apply to me as a hospitalist and my care processes?”

Dr. Dutta sits on the SHM Policy Committee, which has been working to bring these issues to the attention of frontline hospitalists. “Hospitalists are always going to be aligned with their hospital’s priorities. We’re in it to provide high-quality care, but there’s no magic way to do that,” she said.

Hospital Compare measures sometimes end up in hospitalist incentives plans – for example, the readmission penalty rates – even though that is a fairly arbitrary measure and hard to pin to one doctor, Dr. Dutta explained. “If you look at the evidence regarding these metrics, there are not a lot of data to show that the metrics lead to what we really want, which is better care for patients.”

A recent study in the British Medical Journal, for example, examined the association between the penalties on hospitals in the Hospital Acquired Condition Reduction Program and clinical outcome.¹ The researchers concluded that the penalties were not associated with significant change or found to drive meaningful clinical improvement.
 

How can hospitalists engage with Compare?

Dr. Goodrich refers hospitalists seeking quality resources to their local quality improvement organizations (QIO) and to Hospital Improvement Innovation Networks at the regional, state, national, or hospital system level.

One helpful thing that any group of hospitalists could do, added Dr. Figueroa, is to examine the measures closely and determine which ones they think they can influence. “Then look for the hospitals that resemble ours and care for similar patients, based on the demographics. We can then say: ‘Okay, that’s a fair comparison. This can be a benchmark with our peers,’” he said. Then it’s important to ask how your hospital is doing over time on these measures, and use that to prioritize.

“You also have to appreciate that these are broad quality measures, and to impact them you have to do broad quality improvement efforts. Another piece of this is getting good at collecting and analyzing data internally in a timely fashion. You don’t want to wait 2-3 years to find out in Hospital Compare that you’re not performing well. You care about the care you provided today, not 2 or 3 years ago. Without this internal check, it’s impossible to know what to invest in – and to see if things you do are having an impact,” Dr. Figueroa said.

“As physician leaders, this is a real opportunity for us to trigger a conversation with our hospital’s administration around what we went into medicine for in the first place – to improve our patients’ care,” said Dr. Goodrich. She said Hospital Compare is one tool for sparking systemic quality improvement across the hospital – which is an important part of the hospitalist’s job. “If you want to be a bigger star within your hospital, show that level of commitment. It likely would be welcomed by your hospital.”
 

Reference

1. Sankaran R et al. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. BMJ. 2019 Jul 3 doi: 10.1136/bmj.l4109.

CHICAGO – Higher levels of triiodothyronine (T3) were seen in combatants with PTSD, compared with patients whose PTSD arose from other adverse experiences, according to findings from a systematic review and meta-analysis.

Patients with combat-related PTSD had higher levels of free T3 and total T3, compared with control participants who had experienced childhood or sexual abuse or were a wartime refugee without PTSD (FT3, 0.36 pg/mL higher, and total T3, 31.6 ng/mL higher, respectively; P = .0004 and P less than .00001).

“We found statistically higher free T3 and total T3 levels in patients with [combat-related] PTSD, compared with controls,” said Freddy J.K. Toloza, MD, in an interview during a poster session of the annual meeting of the American Thyroid Association.

However, he noted that there were no overall differences in thyroid-stimulating hormone, free tetraiodothyronine (T4), and total T4 levels between individuals with PTSD and the non-PTSD control participants. In addition, though free and total T3 levels were significantly higher for the overall PTSD cohort than for control participants, the differences were driven by the studies that included combat-exposed individuals.

Dr. Toloza and colleagues included 10 observational studies in their final review and meta-analysis. Five studies looked at war veterans; the others examined individuals who had experienced child abuse or sexual abuse, who were refugees, or who were from the general population.

For inclusion, the studies had to report both mean values and standard deviations for standard thyroid-hormone test values in patients with PTSD, compared with a non-PTSD control group. These included 373 patients with PTSD and 301 control participants. Just under half (47%) were women. None of the studies, wrote the investigators, “compared rates of overt/subclinical thyroid disease between groups.”

There are known links between many endocrine disorders and psychiatric conditions, said Dr. Toloza, but the interplay between disordered thyroid function and neuropsychiatric problems is still being examined. Looking at PTSD is important because it’s estimated that 6%-9% of the U.S. adult population has experienced PTSD over the course of a lifetime.

Levels of thyroid hormones in the systematic review and meta-analysis were still within normal range for the participants with PTSD, acknowledged Dr. Toloza, a research fellow in the division of endocrinology and metabolism at University of Arkansas for Medical Sciences, Little Rock.

However, even though there was no sign of frank thyroid disease in the PTSD population, the elevated T3 levels seen in the analysis are consistent with other studies showing a correlation between higher T3 levels and more-severe PTSD.

It is not known exactly why significant increases in the levels of total and free T3 were seen only in the combat-exposed PTSD population, Dr. Toloza said. “The type of trauma trigger may influence the adaptive responses to stress and might result in diverse thyroid alterations.”

Elevated catecholamine levels, seen in individuals with PTSD, can increase peripheral conversion of T4 to T3, explained Dr. Toloza. Ongoing catecholamine elevation may account for the isolated elevation in T3 levels in the PTSD population. Beta1-adrenergic blockade is an accepted pharmacologic strategy to help alleviate PTSD symptoms.

Dr. Toloza and coinvestigators did not have access to data that would have allowed them to ascertain what types of injuries were sustained by individuals with combat-related PTSD, but he noted in response to a question, that it would be worthwhile to see whether combatants who were blast exposed had different thyroid hormone values than those who were not, because hypothalamic injury is common in blast. This is a future direction Dr. Toloza wishes to pursue.

“Our findings add to the growing literature suggesting that thyroid function changes may be associated with PTSD,” the investigators wrote, but “further research is needed to ascertain the role of thyroid function alterations in PTSD.”

Dr. Toloza reported no financial disclosures or conflicts of interest.

CHICAGO – Higher levels of triiodothyronine (T3) were seen in combatants with PTSD, compared with patients whose PTSD arose from other adverse experiences, according to findings from a systematic review and meta-analysis.

Patients with combat-related PTSD had higher levels of free T3 and total T3, compared with control participants who had experienced childhood or sexual abuse or were a wartime refugee without PTSD (FT3, 0.36 pg/mL higher, and total T3, 31.6 ng/mL higher, respectively; P = .0004 and P less than .00001).

“We found statistically higher free T3 and total T3 levels in patients with [combat-related] PTSD, compared with controls,” said Freddy J.K. Toloza, MD, in an interview during a poster session of the annual meeting of the American Thyroid Association.

However, he noted that there were no overall differences in thyroid-stimulating hormone, free tetraiodothyronine (T4), and total T4 levels between individuals with PTSD and the non-PTSD control participants. In addition, though free and total T3 levels were significantly higher for the overall PTSD cohort than for control participants, the differences were driven by the studies that included combat-exposed individuals.

Dr. Toloza and colleagues included 10 observational studies in their final review and meta-analysis. Five studies looked at war veterans; the others examined individuals who had experienced child abuse or sexual abuse, who were refugees, or who were from the general population.

For inclusion, the studies had to report both mean values and standard deviations for standard thyroid-hormone test values in patients with PTSD, compared with a non-PTSD control group. These included 373 patients with PTSD and 301 control participants. Just under half (47%) were women. None of the studies, wrote the investigators, “compared rates of overt/subclinical thyroid disease between groups.”

There are known links between many endocrine disorders and psychiatric conditions, said Dr. Toloza, but the interplay between disordered thyroid function and neuropsychiatric problems is still being examined. Looking at PTSD is important because it’s estimated that 6%-9% of the U.S. adult population has experienced PTSD over the course of a lifetime.

Levels of thyroid hormones in the systematic review and meta-analysis were still within normal range for the participants with PTSD, acknowledged Dr. Toloza, a research fellow in the division of endocrinology and metabolism at University of Arkansas for Medical Sciences, Little Rock.

However, even though there was no sign of frank thyroid disease in the PTSD population, the elevated T3 levels seen in the analysis are consistent with other studies showing a correlation between higher T3 levels and more-severe PTSD.

It is not known exactly why significant increases in the levels of total and free T3 were seen only in the combat-exposed PTSD population, Dr. Toloza said. “The type of trauma trigger may influence the adaptive responses to stress and might result in diverse thyroid alterations.”

Elevated catecholamine levels, seen in individuals with PTSD, can increase peripheral conversion of T4 to T3, explained Dr. Toloza. Ongoing catecholamine elevation may account for the isolated elevation in T3 levels in the PTSD population. Beta1-adrenergic blockade is an accepted pharmacologic strategy to help alleviate PTSD symptoms.

Dr. Toloza and coinvestigators did not have access to data that would have allowed them to ascertain what types of injuries were sustained by individuals with combat-related PTSD, but he noted in response to a question, that it would be worthwhile to see whether combatants who were blast exposed had different thyroid hormone values than those who were not, because hypothalamic injury is common in blast. This is a future direction Dr. Toloza wishes to pursue.

“Our findings add to the growing literature suggesting that thyroid function changes may be associated with PTSD,” the investigators wrote, but “further research is needed to ascertain the role of thyroid function alterations in PTSD.”

Dr. Toloza reported no financial disclosures or conflicts of interest.

CHICAGO – Higher levels of triiodothyronine (T3) were seen in combatants with PTSD, compared with patients whose PTSD arose from other adverse experiences, according to findings from a systematic review and meta-analysis.

Patients with combat-related PTSD had higher levels of free T3 and total T3, compared with control participants who had experienced childhood or sexual abuse or were a wartime refugee without PTSD (FT3, 0.36 pg/mL higher, and total T3, 31.6 ng/mL higher, respectively; P = .0004 and P less than .00001).

“We found statistically higher free T3 and total T3 levels in patients with [combat-related] PTSD, compared with controls,” said Freddy J.K. Toloza, MD, in an interview during a poster session of the annual meeting of the American Thyroid Association.

However, he noted that there were no overall differences in thyroid-stimulating hormone, free tetraiodothyronine (T4), and total T4 levels between individuals with PTSD and the non-PTSD control participants. In addition, though free and total T3 levels were significantly higher for the overall PTSD cohort than for control participants, the differences were driven by the studies that included combat-exposed individuals.

Dr. Toloza and colleagues included 10 observational studies in their final review and meta-analysis. Five studies looked at war veterans; the others examined individuals who had experienced child abuse or sexual abuse, who were refugees, or who were from the general population.

For inclusion, the studies had to report both mean values and standard deviations for standard thyroid-hormone test values in patients with PTSD, compared with a non-PTSD control group. These included 373 patients with PTSD and 301 control participants. Just under half (47%) were women. None of the studies, wrote the investigators, “compared rates of overt/subclinical thyroid disease between groups.”

There are known links between many endocrine disorders and psychiatric conditions, said Dr. Toloza, but the interplay between disordered thyroid function and neuropsychiatric problems is still being examined. Looking at PTSD is important because it’s estimated that 6%-9% of the U.S. adult population has experienced PTSD over the course of a lifetime.

Levels of thyroid hormones in the systematic review and meta-analysis were still within normal range for the participants with PTSD, acknowledged Dr. Toloza, a research fellow in the division of endocrinology and metabolism at University of Arkansas for Medical Sciences, Little Rock.

However, even though there was no sign of frank thyroid disease in the PTSD population, the elevated T3 levels seen in the analysis are consistent with other studies showing a correlation between higher T3 levels and more-severe PTSD.

It is not known exactly why significant increases in the levels of total and free T3 were seen only in the combat-exposed PTSD population, Dr. Toloza said. “The type of trauma trigger may influence the adaptive responses to stress and might result in diverse thyroid alterations.”

Elevated catecholamine levels, seen in individuals with PTSD, can increase peripheral conversion of T4 to T3, explained Dr. Toloza. Ongoing catecholamine elevation may account for the isolated elevation in T3 levels in the PTSD population. Beta1-adrenergic blockade is an accepted pharmacologic strategy to help alleviate PTSD symptoms.

Dr. Toloza and coinvestigators did not have access to data that would have allowed them to ascertain what types of injuries were sustained by individuals with combat-related PTSD, but he noted in response to a question, that it would be worthwhile to see whether combatants who were blast exposed had different thyroid hormone values than those who were not, because hypothalamic injury is common in blast. This is a future direction Dr. Toloza wishes to pursue.

“Our findings add to the growing literature suggesting that thyroid function changes may be associated with PTSD,” the investigators wrote, but “further research is needed to ascertain the role of thyroid function alterations in PTSD.”

Dr. Toloza reported no financial disclosures or conflicts of interest.