Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. ICU pressures improve transfers to the floor
2. Morbidity, mortality rates high for respiratory syncytial virus infections
3. Antibiotic algorithm can guide therapy in healthcare-associated pneumonia
4. Three-month dual antiplatelet therapy for zotarolimus-eluting stents
5. De-escalating antibiotics in sepsis
6. New oral anticoagulants increase GI bleed risk
7. Single vs. dual antiplatelet therapy after stroke
8. Endoscopic vs. surgical cystogastrostomy for pancreatic pseudocyst drainage
9. Long-term cognitive impairment after critical illness
10. Holding chambers vs. nebulizers for acute asthma

ICU Pressures Improve Transfers to the Floor

Clinical question: Does ICU strain negatively affect the outcomes of patients transferred to the floor?

Background: With healthcare costs increasing and critical care staff shortages projected, ICUs will have to operate under increasing strain. This may influence decisions on discharging patients from ICUs and could affect patient outcomes.

Study design: Retrospective cohort study.

Setting: One hundred fifty-five ICUs in the United States.

Synopsis: Using the Project IMPACT database, 200,730 adult patients from 107 different hospitals were evaluated in times of ICU strain, determined by the current census, new admissions, and acuity level. Outcomes measured were initial ICU length of stay (LOS), readmission within 72 hours, in-hospital mortality rates, and post-ICU discharge LOS.

Increases of the strain variables from the fifth to the 95th percentiles resulted in a 6.3-hour reduction in ICU LOS, a 2.0-hour decrease in post-ICU discharge LOS, and a 1.0% increase in probability of ICU readmission within 72 hours. Mortality rates during the hospital stay and odds of being discharged home showed no significant change. This study was limited because the ICUs participating were not randomly chosen, outcomes of patients transferred to other hospitals were not measured, and no post-hospital data was collected, so no long-term outcomes could be measured.

Bottom line: ICU bed pressures prompt physicians to allocate ICU resources more efficiently without changing short-term patient outcomes.

Citation: Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455.

Adults Hospitalized for Respiratory Syncytial Virus Infections Have High Morbidity, Mortality Rates

Clinical question: What are the complications and outcomes of respiratory syncytial virus (RSV) infection in adults requiring hospitalization?

Background: RSV is a common cause of lower respiratory tract infection in infants and young children, leading to hospitalization and even death. RSV has been estimated to affect 3%-10% of adults annually, generally causing mild disease. However, the outcomes of adults with more severe disease are not fully known.

Study design: Retrospective cohort study.

Setting: Three acute care, public hospitals in Hong Kong.

Synopsis: All adult patients hospitalized with laboratory-confirmed RSV infection were included during the defined time period. The main outcome measure was all-cause death, with secondary outcome measures of development of acute respiratory failure requiring ventilator support and total duration of hospitalization among survivors. Additionally, the cohort of RSV patients was compared to patients admitted with seasonal influenza during this same time frame. Patients with pandemic 2009 H1N1 infection were not included.

Of patients with RSV, pneumonia was found in 42.3%, bacterial superinfection in 12.5%, and cardiovascular complications in 14.3%. Additionally, 11.1% developed respiratory failure requiring ventilator support. All-cause mortality at 30 days and 60 days was 9.1% and 11.9%, respectively, with pneumonia the most common cause of death. Use of systemic corticosteroids did not improve survival. When the RSV cohort was compared to the influenza cohort, the patients were similar in age, but the RSV patients were more likely to have underlying chronic lung disease and major systemic co-morbidities. The rate of survival and duration of hospitalization were not significantly different.

Bottom line: RSV infection is an underappreciated cause of lower tract respiratory infection in adults; severe infections that require hospitalization have rates of mortality similar to seasonal influenza. Further research on treatment or immunization is needed.

Citation: Lee N, Lui GC, Wong KT, et al. High morbidity and mortality in adults hospitalized for respiratory syncytial virus infections. Clin Infect Dis. 2013;57(8):1069-1077.

Antibiotic Algorithm Can Guide Therapy in Healthcare-Associated Pneumonia

Clinical question: Can an algorithm based on risk for multidrug-resistant (MDR) organisms and illness severity guide antibiotic selection in healthcare-associated pneumonia (HCAP)?

Background: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines identify patients with HCAP as those with recent contact with a healthcare environment, including nursing homes and hemodialysis; however, previous studies have shown that not all patients with healthcare contact have equal risk for MDR organisms.

Study design: Prospective cohort study.

Setting: Japan, multi-center.

Synopsis: Of the 445 enrolled patients, 124 were diagnosed with community-acquired pneumonia (CAP) and 321 with HCAP. Patients with HCAP were classified based on severity of illness or MDR pathogen risk factors (immune suppression, hospitalization within the last 90 days, poor functional status, and antibiotics within the past six months). Patients with low risk (0-1 factors) for MDR organisms were treated for CAP, and patients with high risk (≥2 factors) or moderate risk (≥1 factor) for severe illness were treated for HCAP.

HCAP patients had a higher 30-day mortality rate (13.7% vs. 5.6%, P=0.017), but mortality rate was less in the patients at low risk for MDR pathogens (8.6% vs. 18.2%, P=0.012). Of the HCAP patients, only 7.1% received inappropriate therapy (pathogen resistant to initial antibiotic regimen), and treatment failure was 19.3%.

Appropriateness of initial empiric therapy was determined not to be a mortality risk; however, this trial might be limited by its location, because Japan appears to have fewer MDR pathogens than the U.S.

Bottom line: A treatment algorithm based on risk for MDR organisms and severity of illness can be used to guide empiric antibiotic therapy in patients with HCAP, and, ideally, to reduce excessive use of broad-spectrum antibiotics.

Citation: Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013;57(10):1373-1383.

Three-Month Dual Antiplatelet Therapy for Zotarolimus-Eluting Stents

Clinical question: Is short-term, dual antiplatelet therapy noninferior to long-term therapy in zotarolimus-eluting stents?

Background: Current guidelines recommend long-term (>12 months) dual antiplatelet therapy after the placement of drug-eluting stents. The optimal therapy duration in second-generation drug-eluting stents has not been studied; moreover, some studies with multiple drug-eluting stents have suggested no added benefit from long-term therapy.

Study design: Randomized controlled trial.

Setting: Brazil, multi-center.

Synopsis: Researchers randomized 3,211 patients with stable coronary artery disease (CAD) or low-risk acute coronary syndrome (ACS) undergoing intervention with zotarolimus-eluting stents to short-term (three months) or long-term (12 months) dual antiplatelet therapy. Exclusion criteria included ST-elevation myocardial infarction (STEMI), previous drug-eluting stent, scheduled elective surgery within 12 months, or contraindication to aspirin or clopidogrel. Primary endpoints were a composite of death from any cause, MI, stroke, or major bleeding. Secondary endpoints were stent thrombosis, target lesion revascularization, adverse cardiac event, and any bleed.

At one-year follow-up, the short-term group had similar primary (6.0% vs. 5.8%) and secondary (8.3% vs. 7.4%) outcomes compared to the long-term. The short-term group’s noninferiority also was seen in several key subgroups.

This study included patients with stable CAD or low-risk ACS and cannot be generalized to higher-risk patients. Results for zotarolimus-eluting stents cannot be generalized to other second-generation drug-eluting stents.

Bottom line: Zotarolimus-eluting stents, followed by three months of dual antiplatelet therapy, were noninferior to 12 months of therapy in patients with stable CAD or low-risk ACS.

Citation: Feres F, Costa RA, Abizaid A, et al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-2522.

De-Escalating Antibiotics in Sepsis

Clinical question: Does tailoring antibiotics based on known pathogens impact mortality for patients with severe sepsis or shock?

Background: In patients with sepsis, the use of early empiric antibiotics reduces morbidity and mortality. De-escalation therapy refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known; however, no randomized controlled studies have assessed the impact of this therapy on critically ill patients.

Study design: Prospective observational study.

Setting: Academic hospital ICU in Spain.

Synopsis: From January 2008 to May 2012, 628 adult patients were treated empirically with broad-spectrum antibiotics. De-escalation was applied to 219 patients (34.9%). Outcomes measured were ICU mortality, hospital mortality, and 90-day mortality in patients who received de-escalation therapy, patients whose antibiotics were not changed, and patients for whom antibiotics were escalated.

The in-hospital mortality rate was 27.4% in patients who were de-escalated, 32.6% in the unchanged group, and 42.9% in the escalation group. ICU and 90-day mortality were lower in the de-escalation group. De-escalation was more commonly used in medical than in surgical patients.

This study is limited because it is not a randomized controlled study and was single-centered, so it might only be applicable on the larger scale. Also, multi-drug resistant organisms were not evaluated.

Overall, it is safe to narrow empiric antibiotics in severe sepsis and shock when the pathogen and sensitivities are known.

Bottom line: De-escalation of antibiotics in severe sepsis and septic shock is associated with a lower mortality.

Citation: Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40.

New Oral Anticoagulants Increase GI Bleed Risk

Clinical question: Do thrombin and factor Xa inhibitors increase the risk of gastrointestinal (GI) bleeding when compared to vitamin K antagonists and heparins?

Background: New oral anticoagulants (thrombin and factor Xa inhibitors) are available and being used with increased frequency due to equal efficacy and ease of administration. Some studies indicate a higher risk of GI bleeding with these agents. Further evaluation is needed, because no reversal therapy is available.

Study design: Systematic review and meta-analysis.

Setting: Data from MEDLINE, Embase, and the Cochrane Library.

Synopsis: More than 150,000 patients from 43 randomized controlled trials were evaluated for risk of GI bleed when treated with new anticoagulants versus traditional therapy. Patients were treated for one of the following: embolism prevention from atrial fibrillation, venous thromboembolism (VTE) prophylaxis post orthopedic surgery, VTE prophylaxis of medical patients, acute VTE, and acute coronary syndrome (ACS). Use of aspirin or NSAIDs was discouraged but not documented. The odds ratio for GI bleeding with use of the new anticoagulants was 1.45, with a number needed to harm of 500. Evaluation of subgroups revealed increased GI bleed risk in patients treated for ACS and acute thrombosis versus prophylaxis. Post-surgical patients had the lowest risk.

This study was limited by the heterogeneity and differing primary outcomes (mostly efficacy rather than safety) of the included trials. Studies excluded high-risk patients, which the authors estimate to be 25%-40% of actual patients. More studies need to be done that include high-risk patients and focus on GI bleed as a primary outcome.

Bottom line: The new anticoagulants tend to have a higher incidence of GI bleed than traditional therapy, but this varies based on indication of therapy and needs further evaluation to clarify risk.

Citation: Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.

Single vs. Dual Antiplatelet Therapy after Stroke

Clinical question: Is dual antiplatelet therapy more beneficial or harmful than monotherapy after ischemic stroke?

Background: It is recommended that patients with ischemic stroke or transient ischemic attack (TIA) receive lifelong antiplatelet therapy; however, there have been insufficient studies evaluating the long-term safety of dual antiplatelet therapy.

Study design: Meta-analysis of randomized controlled trials (RCTs)

Setting: Data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Synopsis: Data from seven RCTs, including 39,574 patients with recent TIA or ischemic stroke, were reviewed. Comparisons were made regarding occurrence of intracranial hemorrhage (ICH) and recurrent stroke between patients receiving dual antiplatelet therapy and those receiving aspirin or clopidogrel monotherapy. All patients were treated for at least one year.

There was no difference in recurrent stroke or ICH between patients on dual antiplatelet therapy versus aspirin monotherapy. Patients treated with dual antiplatelet therapy did have a 46% increased risk of ICH without any additional protective benefit for recurrent stroke or TIA when compared with patients on clopidogrel monotherapy.

This information should not be applied in the acute setting, given the high risk of stroke after TIA or ischemic stroke. One major limitation of this study was that the individual trials used different combinations of dual antiplatelet therapy.

Bottom line: The risk of recurrent stroke or TIA after dual antiplatelet therapy and after monotherapy with aspirin or clopidogrel is equal, but the risk of ICH compared to clopidogrel monotherapy is increased.

Citation: Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis. Ann Intern Med. 2013;159(7):463-470.

Endoscopic vs. Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage

Clinical question: How does endoscopic cystogastrostomy for pancreatic pseudocyst drainage compare to the standard surgical approach?

Background: Pancreatic pseudocysts are a common complication of pancreatitis and necessitate decompression when they are accompanied by pain, infection, or obstruction. Decompression of the pseudocyst can be accomplished using either endoscopic or surgical cystogastrostomy.

Study design: Open-label, single-center, randomized trial.

Setting: Single-center U.S. hospital.

Synopsis: A total of 40 patients were randomly equalized to both treatment arms; 20 patients underwent endoscopic and 20 patients underwent surgical cystogastrostomy. Zero patients in the endoscopic therapy had a pseudocyst recurrence, compared with one patient treated surgically. Length of stay (LOS) and cost were lower for the endoscopic group compared to the surgical group (two days vs. six days, P<0.001, $7,011 vs. $15,052, P=0.003).

This study is limited due to several factors. First, patients with pancreatic necrosis were excluded; had these patients been included, the complication rates and LOS would have been higher. Second, cost difference cannot be generalized across the U.S., because Medicare payments are based on provider types and regions.

Bottom line: Endoscopic cystogastrostomy for pancreatic pseudocyst is equal to the standard surgical therapy and results in decreased LOS and reduced costs.

Citation: Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583-590.

Long-Term Cognitive Impairment after Critical Illness

Clinical question: Are a longer duration of delirium and higher doses of sedatives associated with cognitive impairment in the hospital?

Background: Survivors of critical illness are at risk for prolonged cognitive dysfunction. Delirium (and factors associated with delirium, namely sedative and analgesic medications) has been implicated in cognitive dysfunction.

Study design: Prospective cohort study.

Setting: Multi-center, academic, and acute care hospitals.

Synopsis: The study examined 821 adults admitted to the ICU with respiratory failure, cardiogenic shock, or septic shock. Patients excluded were those with pre-existing cognitive impairment, those with psychotic disorders, and those for whom follow-up would not be possible. Two risk factors measured were duration of delirium and use of sedative/analgesics. Delirium was assessed at three and 12 months using the CAM-ICU algorithm in the ICU by trained psychology professionals who were unaware of the patients’ in-hospital course.

At three months, 40% of patients had global cognition scores that were 1.5 standard deviations (SD) below population mean (similar to traumatic brain injury), and 26% had scores two SD below population mean (similar to mild Alzheimer’s). At 12 months, 34% had scores similar to traumatic brain injury patients, and 24% had scores similar to mild Alzheimer’s. A longer duration of delirium was associated with worse global cognition at three and 12 months. Use of sedatives/analgesics was not associated with cognitive impairment.

Bottom line: Critically ill patients in the ICU who experience a longer duration of delirium are at risk of long-term cognitive impairments lasting 12 months.

Citation: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.

Holding Chambers (Spacers) vs. Nebulizers for Acute Asthma

Clinical question: Are beta-2 agonists as effective when administered through a holding chamber (spacer) as they are when administered by a nebulizer?

Background: During an acute asthma attack, beta-2 agonists must be delivered to the peripheral airways. There has been considerable controversy regarding the use of a spacer compared with a nebulizer. Aside from admission rates and length of stay, factors taken into account include cost, maintenance of nebulizer machines, and infection control (potential of cross-infection via nebulizers).

Study design: Meta-analysis review of randomized controlled trials (RCTs).

Setting: Multi-centered, worldwide studies from community setting and EDs.

Synopsis: In 39 studies of patients with an acute asthma attack (selected from Cochrane Airways Group Specialized Register), the hospital admission rates did not differ on the basis of delivery method in 729 adults (risk ratio=0.94, confidence interval 0.61-1.43) or in 1,897 children (risk ratio=0.71, confidence interval 0.47-1.08). Secondary outcomes included the duration of time in the ED and the duration of hospital admission. Time spent in the ED varied for adults but was shorter for children with spacers (based on three studies). Duration of hospital admission also did not differ when modes of delivery were compared.

Bottom line: Providing beta-2 agonists using nebulizers during an acute asthma attack is not more effective than administration using a spacer.

Citation: Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. ICU pressures improve transfers to the floor
2. Morbidity, mortality rates high for respiratory syncytial virus infections
3. Antibiotic algorithm can guide therapy in healthcare-associated pneumonia
4. Three-month dual antiplatelet therapy for zotarolimus-eluting stents
5. De-escalating antibiotics in sepsis
6. New oral anticoagulants increase GI bleed risk
7. Single vs. dual antiplatelet therapy after stroke
8. Endoscopic vs. surgical cystogastrostomy for pancreatic pseudocyst drainage
9. Long-term cognitive impairment after critical illness
10. Holding chambers vs. nebulizers for acute asthma

ICU Pressures Improve Transfers to the Floor

Clinical question: Does ICU strain negatively affect the outcomes of patients transferred to the floor?

Background: With healthcare costs increasing and critical care staff shortages projected, ICUs will have to operate under increasing strain. This may influence decisions on discharging patients from ICUs and could affect patient outcomes.

Study design: Retrospective cohort study.

Setting: One hundred fifty-five ICUs in the United States.

Synopsis: Using the Project IMPACT database, 200,730 adult patients from 107 different hospitals were evaluated in times of ICU strain, determined by the current census, new admissions, and acuity level. Outcomes measured were initial ICU length of stay (LOS), readmission within 72 hours, in-hospital mortality rates, and post-ICU discharge LOS.

Increases of the strain variables from the fifth to the 95th percentiles resulted in a 6.3-hour reduction in ICU LOS, a 2.0-hour decrease in post-ICU discharge LOS, and a 1.0% increase in probability of ICU readmission within 72 hours. Mortality rates during the hospital stay and odds of being discharged home showed no significant change. This study was limited because the ICUs participating were not randomly chosen, outcomes of patients transferred to other hospitals were not measured, and no post-hospital data was collected, so no long-term outcomes could be measured.

Bottom line: ICU bed pressures prompt physicians to allocate ICU resources more efficiently without changing short-term patient outcomes.

Citation: Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455.

Adults Hospitalized for Respiratory Syncytial Virus Infections Have High Morbidity, Mortality Rates

Clinical question: What are the complications and outcomes of respiratory syncytial virus (RSV) infection in adults requiring hospitalization?

Background: RSV is a common cause of lower respiratory tract infection in infants and young children, leading to hospitalization and even death. RSV has been estimated to affect 3%-10% of adults annually, generally causing mild disease. However, the outcomes of adults with more severe disease are not fully known.

Study design: Retrospective cohort study.

Setting: Three acute care, public hospitals in Hong Kong.

Synopsis: All adult patients hospitalized with laboratory-confirmed RSV infection were included during the defined time period. The main outcome measure was all-cause death, with secondary outcome measures of development of acute respiratory failure requiring ventilator support and total duration of hospitalization among survivors. Additionally, the cohort of RSV patients was compared to patients admitted with seasonal influenza during this same time frame. Patients with pandemic 2009 H1N1 infection were not included.

Of patients with RSV, pneumonia was found in 42.3%, bacterial superinfection in 12.5%, and cardiovascular complications in 14.3%. Additionally, 11.1% developed respiratory failure requiring ventilator support. All-cause mortality at 30 days and 60 days was 9.1% and 11.9%, respectively, with pneumonia the most common cause of death. Use of systemic corticosteroids did not improve survival. When the RSV cohort was compared to the influenza cohort, the patients were similar in age, but the RSV patients were more likely to have underlying chronic lung disease and major systemic co-morbidities. The rate of survival and duration of hospitalization were not significantly different.

Bottom line: RSV infection is an underappreciated cause of lower tract respiratory infection in adults; severe infections that require hospitalization have rates of mortality similar to seasonal influenza. Further research on treatment or immunization is needed.

Citation: Lee N, Lui GC, Wong KT, et al. High morbidity and mortality in adults hospitalized for respiratory syncytial virus infections. Clin Infect Dis. 2013;57(8):1069-1077.

Antibiotic Algorithm Can Guide Therapy in Healthcare-Associated Pneumonia

Clinical question: Can an algorithm based on risk for multidrug-resistant (MDR) organisms and illness severity guide antibiotic selection in healthcare-associated pneumonia (HCAP)?

Background: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines identify patients with HCAP as those with recent contact with a healthcare environment, including nursing homes and hemodialysis; however, previous studies have shown that not all patients with healthcare contact have equal risk for MDR organisms.

Study design: Prospective cohort study.

Setting: Japan, multi-center.

Synopsis: Of the 445 enrolled patients, 124 were diagnosed with community-acquired pneumonia (CAP) and 321 with HCAP. Patients with HCAP were classified based on severity of illness or MDR pathogen risk factors (immune suppression, hospitalization within the last 90 days, poor functional status, and antibiotics within the past six months). Patients with low risk (0-1 factors) for MDR organisms were treated for CAP, and patients with high risk (≥2 factors) or moderate risk (≥1 factor) for severe illness were treated for HCAP.

HCAP patients had a higher 30-day mortality rate (13.7% vs. 5.6%, P=0.017), but mortality rate was less in the patients at low risk for MDR pathogens (8.6% vs. 18.2%, P=0.012). Of the HCAP patients, only 7.1% received inappropriate therapy (pathogen resistant to initial antibiotic regimen), and treatment failure was 19.3%.

Appropriateness of initial empiric therapy was determined not to be a mortality risk; however, this trial might be limited by its location, because Japan appears to have fewer MDR pathogens than the U.S.

Bottom line: A treatment algorithm based on risk for MDR organisms and severity of illness can be used to guide empiric antibiotic therapy in patients with HCAP, and, ideally, to reduce excessive use of broad-spectrum antibiotics.

Citation: Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013;57(10):1373-1383.

Three-Month Dual Antiplatelet Therapy for Zotarolimus-Eluting Stents

Clinical question: Is short-term, dual antiplatelet therapy noninferior to long-term therapy in zotarolimus-eluting stents?

Background: Current guidelines recommend long-term (>12 months) dual antiplatelet therapy after the placement of drug-eluting stents. The optimal therapy duration in second-generation drug-eluting stents has not been studied; moreover, some studies with multiple drug-eluting stents have suggested no added benefit from long-term therapy.

Study design: Randomized controlled trial.

Setting: Brazil, multi-center.

Synopsis: Researchers randomized 3,211 patients with stable coronary artery disease (CAD) or low-risk acute coronary syndrome (ACS) undergoing intervention with zotarolimus-eluting stents to short-term (three months) or long-term (12 months) dual antiplatelet therapy. Exclusion criteria included ST-elevation myocardial infarction (STEMI), previous drug-eluting stent, scheduled elective surgery within 12 months, or contraindication to aspirin or clopidogrel. Primary endpoints were a composite of death from any cause, MI, stroke, or major bleeding. Secondary endpoints were stent thrombosis, target lesion revascularization, adverse cardiac event, and any bleed.

At one-year follow-up, the short-term group had similar primary (6.0% vs. 5.8%) and secondary (8.3% vs. 7.4%) outcomes compared to the long-term. The short-term group’s noninferiority also was seen in several key subgroups.

This study included patients with stable CAD or low-risk ACS and cannot be generalized to higher-risk patients. Results for zotarolimus-eluting stents cannot be generalized to other second-generation drug-eluting stents.

Bottom line: Zotarolimus-eluting stents, followed by three months of dual antiplatelet therapy, were noninferior to 12 months of therapy in patients with stable CAD or low-risk ACS.

Citation: Feres F, Costa RA, Abizaid A, et al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-2522.

De-Escalating Antibiotics in Sepsis

Clinical question: Does tailoring antibiotics based on known pathogens impact mortality for patients with severe sepsis or shock?

Background: In patients with sepsis, the use of early empiric antibiotics reduces morbidity and mortality. De-escalation therapy refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known; however, no randomized controlled studies have assessed the impact of this therapy on critically ill patients.

Study design: Prospective observational study.

Setting: Academic hospital ICU in Spain.

Synopsis: From January 2008 to May 2012, 628 adult patients were treated empirically with broad-spectrum antibiotics. De-escalation was applied to 219 patients (34.9%). Outcomes measured were ICU mortality, hospital mortality, and 90-day mortality in patients who received de-escalation therapy, patients whose antibiotics were not changed, and patients for whom antibiotics were escalated.

The in-hospital mortality rate was 27.4% in patients who were de-escalated, 32.6% in the unchanged group, and 42.9% in the escalation group. ICU and 90-day mortality were lower in the de-escalation group. De-escalation was more commonly used in medical than in surgical patients.

This study is limited because it is not a randomized controlled study and was single-centered, so it might only be applicable on the larger scale. Also, multi-drug resistant organisms were not evaluated.

Overall, it is safe to narrow empiric antibiotics in severe sepsis and shock when the pathogen and sensitivities are known.

Bottom line: De-escalation of antibiotics in severe sepsis and septic shock is associated with a lower mortality.

Citation: Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40.

New Oral Anticoagulants Increase GI Bleed Risk

Clinical question: Do thrombin and factor Xa inhibitors increase the risk of gastrointestinal (GI) bleeding when compared to vitamin K antagonists and heparins?

Background: New oral anticoagulants (thrombin and factor Xa inhibitors) are available and being used with increased frequency due to equal efficacy and ease of administration. Some studies indicate a higher risk of GI bleeding with these agents. Further evaluation is needed, because no reversal therapy is available.

Study design: Systematic review and meta-analysis.

Setting: Data from MEDLINE, Embase, and the Cochrane Library.

Synopsis: More than 150,000 patients from 43 randomized controlled trials were evaluated for risk of GI bleed when treated with new anticoagulants versus traditional therapy. Patients were treated for one of the following: embolism prevention from atrial fibrillation, venous thromboembolism (VTE) prophylaxis post orthopedic surgery, VTE prophylaxis of medical patients, acute VTE, and acute coronary syndrome (ACS). Use of aspirin or NSAIDs was discouraged but not documented. The odds ratio for GI bleeding with use of the new anticoagulants was 1.45, with a number needed to harm of 500. Evaluation of subgroups revealed increased GI bleed risk in patients treated for ACS and acute thrombosis versus prophylaxis. Post-surgical patients had the lowest risk.

This study was limited by the heterogeneity and differing primary outcomes (mostly efficacy rather than safety) of the included trials. Studies excluded high-risk patients, which the authors estimate to be 25%-40% of actual patients. More studies need to be done that include high-risk patients and focus on GI bleed as a primary outcome.

Bottom line: The new anticoagulants tend to have a higher incidence of GI bleed than traditional therapy, but this varies based on indication of therapy and needs further evaluation to clarify risk.

Citation: Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.

Single vs. Dual Antiplatelet Therapy after Stroke

Clinical question: Is dual antiplatelet therapy more beneficial or harmful than monotherapy after ischemic stroke?

Background: It is recommended that patients with ischemic stroke or transient ischemic attack (TIA) receive lifelong antiplatelet therapy; however, there have been insufficient studies evaluating the long-term safety of dual antiplatelet therapy.

Study design: Meta-analysis of randomized controlled trials (RCTs)

Setting: Data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Synopsis: Data from seven RCTs, including 39,574 patients with recent TIA or ischemic stroke, were reviewed. Comparisons were made regarding occurrence of intracranial hemorrhage (ICH) and recurrent stroke between patients receiving dual antiplatelet therapy and those receiving aspirin or clopidogrel monotherapy. All patients were treated for at least one year.

There was no difference in recurrent stroke or ICH between patients on dual antiplatelet therapy versus aspirin monotherapy. Patients treated with dual antiplatelet therapy did have a 46% increased risk of ICH without any additional protective benefit for recurrent stroke or TIA when compared with patients on clopidogrel monotherapy.

This information should not be applied in the acute setting, given the high risk of stroke after TIA or ischemic stroke. One major limitation of this study was that the individual trials used different combinations of dual antiplatelet therapy.

Bottom line: The risk of recurrent stroke or TIA after dual antiplatelet therapy and after monotherapy with aspirin or clopidogrel is equal, but the risk of ICH compared to clopidogrel monotherapy is increased.

Citation: Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis. Ann Intern Med. 2013;159(7):463-470.

Endoscopic vs. Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage

Clinical question: How does endoscopic cystogastrostomy for pancreatic pseudocyst drainage compare to the standard surgical approach?

Background: Pancreatic pseudocysts are a common complication of pancreatitis and necessitate decompression when they are accompanied by pain, infection, or obstruction. Decompression of the pseudocyst can be accomplished using either endoscopic or surgical cystogastrostomy.

Study design: Open-label, single-center, randomized trial.

Setting: Single-center U.S. hospital.

Synopsis: A total of 40 patients were randomly equalized to both treatment arms; 20 patients underwent endoscopic and 20 patients underwent surgical cystogastrostomy. Zero patients in the endoscopic therapy had a pseudocyst recurrence, compared with one patient treated surgically. Length of stay (LOS) and cost were lower for the endoscopic group compared to the surgical group (two days vs. six days, P<0.001, $7,011 vs. $15,052, P=0.003).

This study is limited due to several factors. First, patients with pancreatic necrosis were excluded; had these patients been included, the complication rates and LOS would have been higher. Second, cost difference cannot be generalized across the U.S., because Medicare payments are based on provider types and regions.

Bottom line: Endoscopic cystogastrostomy for pancreatic pseudocyst is equal to the standard surgical therapy and results in decreased LOS and reduced costs.

Citation: Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583-590.

Long-Term Cognitive Impairment after Critical Illness

Clinical question: Are a longer duration of delirium and higher doses of sedatives associated with cognitive impairment in the hospital?

Background: Survivors of critical illness are at risk for prolonged cognitive dysfunction. Delirium (and factors associated with delirium, namely sedative and analgesic medications) has been implicated in cognitive dysfunction.

Study design: Prospective cohort study.

Setting: Multi-center, academic, and acute care hospitals.

Synopsis: The study examined 821 adults admitted to the ICU with respiratory failure, cardiogenic shock, or septic shock. Patients excluded were those with pre-existing cognitive impairment, those with psychotic disorders, and those for whom follow-up would not be possible. Two risk factors measured were duration of delirium and use of sedative/analgesics. Delirium was assessed at three and 12 months using the CAM-ICU algorithm in the ICU by trained psychology professionals who were unaware of the patients’ in-hospital course.

At three months, 40% of patients had global cognition scores that were 1.5 standard deviations (SD) below population mean (similar to traumatic brain injury), and 26% had scores two SD below population mean (similar to mild Alzheimer’s). At 12 months, 34% had scores similar to traumatic brain injury patients, and 24% had scores similar to mild Alzheimer’s. A longer duration of delirium was associated with worse global cognition at three and 12 months. Use of sedatives/analgesics was not associated with cognitive impairment.

Bottom line: Critically ill patients in the ICU who experience a longer duration of delirium are at risk of long-term cognitive impairments lasting 12 months.

Citation: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.

Holding Chambers (Spacers) vs. Nebulizers for Acute Asthma

Clinical question: Are beta-2 agonists as effective when administered through a holding chamber (spacer) as they are when administered by a nebulizer?

Background: During an acute asthma attack, beta-2 agonists must be delivered to the peripheral airways. There has been considerable controversy regarding the use of a spacer compared with a nebulizer. Aside from admission rates and length of stay, factors taken into account include cost, maintenance of nebulizer machines, and infection control (potential of cross-infection via nebulizers).

Study design: Meta-analysis review of randomized controlled trials (RCTs).

Setting: Multi-centered, worldwide studies from community setting and EDs.

Synopsis: In 39 studies of patients with an acute asthma attack (selected from Cochrane Airways Group Specialized Register), the hospital admission rates did not differ on the basis of delivery method in 729 adults (risk ratio=0.94, confidence interval 0.61-1.43) or in 1,897 children (risk ratio=0.71, confidence interval 0.47-1.08). Secondary outcomes included the duration of time in the ED and the duration of hospital admission. Time spent in the ED varied for adults but was shorter for children with spacers (based on three studies). Duration of hospital admission also did not differ when modes of delivery were compared.

Bottom line: Providing beta-2 agonists using nebulizers during an acute asthma attack is not more effective than administration using a spacer.

Citation: Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. ICU pressures improve transfers to the floor
2. Morbidity, mortality rates high for respiratory syncytial virus infections
3. Antibiotic algorithm can guide therapy in healthcare-associated pneumonia
4. Three-month dual antiplatelet therapy for zotarolimus-eluting stents
5. De-escalating antibiotics in sepsis
6. New oral anticoagulants increase GI bleed risk
7. Single vs. dual antiplatelet therapy after stroke
8. Endoscopic vs. surgical cystogastrostomy for pancreatic pseudocyst drainage
9. Long-term cognitive impairment after critical illness
10. Holding chambers vs. nebulizers for acute asthma

ICU Pressures Improve Transfers to the Floor

Clinical question: Does ICU strain negatively affect the outcomes of patients transferred to the floor?

Background: With healthcare costs increasing and critical care staff shortages projected, ICUs will have to operate under increasing strain. This may influence decisions on discharging patients from ICUs and could affect patient outcomes.

Study design: Retrospective cohort study.

Setting: One hundred fifty-five ICUs in the United States.

Synopsis: Using the Project IMPACT database, 200,730 adult patients from 107 different hospitals were evaluated in times of ICU strain, determined by the current census, new admissions, and acuity level. Outcomes measured were initial ICU length of stay (LOS), readmission within 72 hours, in-hospital mortality rates, and post-ICU discharge LOS.

Increases of the strain variables from the fifth to the 95th percentiles resulted in a 6.3-hour reduction in ICU LOS, a 2.0-hour decrease in post-ICU discharge LOS, and a 1.0% increase in probability of ICU readmission within 72 hours. Mortality rates during the hospital stay and odds of being discharged home showed no significant change. This study was limited because the ICUs participating were not randomly chosen, outcomes of patients transferred to other hospitals were not measured, and no post-hospital data was collected, so no long-term outcomes could be measured.

Bottom line: ICU bed pressures prompt physicians to allocate ICU resources more efficiently without changing short-term patient outcomes.

Citation: Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455.

Adults Hospitalized for Respiratory Syncytial Virus Infections Have High Morbidity, Mortality Rates

Clinical question: What are the complications and outcomes of respiratory syncytial virus (RSV) infection in adults requiring hospitalization?

Background: RSV is a common cause of lower respiratory tract infection in infants and young children, leading to hospitalization and even death. RSV has been estimated to affect 3%-10% of adults annually, generally causing mild disease. However, the outcomes of adults with more severe disease are not fully known.

Study design: Retrospective cohort study.

Setting: Three acute care, public hospitals in Hong Kong.

Synopsis: All adult patients hospitalized with laboratory-confirmed RSV infection were included during the defined time period. The main outcome measure was all-cause death, with secondary outcome measures of development of acute respiratory failure requiring ventilator support and total duration of hospitalization among survivors. Additionally, the cohort of RSV patients was compared to patients admitted with seasonal influenza during this same time frame. Patients with pandemic 2009 H1N1 infection were not included.

Of patients with RSV, pneumonia was found in 42.3%, bacterial superinfection in 12.5%, and cardiovascular complications in 14.3%. Additionally, 11.1% developed respiratory failure requiring ventilator support. All-cause mortality at 30 days and 60 days was 9.1% and 11.9%, respectively, with pneumonia the most common cause of death. Use of systemic corticosteroids did not improve survival. When the RSV cohort was compared to the influenza cohort, the patients were similar in age, but the RSV patients were more likely to have underlying chronic lung disease and major systemic co-morbidities. The rate of survival and duration of hospitalization were not significantly different.

Bottom line: RSV infection is an underappreciated cause of lower tract respiratory infection in adults; severe infections that require hospitalization have rates of mortality similar to seasonal influenza. Further research on treatment or immunization is needed.

Citation: Lee N, Lui GC, Wong KT, et al. High morbidity and mortality in adults hospitalized for respiratory syncytial virus infections. Clin Infect Dis. 2013;57(8):1069-1077.

Antibiotic Algorithm Can Guide Therapy in Healthcare-Associated Pneumonia

Clinical question: Can an algorithm based on risk for multidrug-resistant (MDR) organisms and illness severity guide antibiotic selection in healthcare-associated pneumonia (HCAP)?

Background: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines identify patients with HCAP as those with recent contact with a healthcare environment, including nursing homes and hemodialysis; however, previous studies have shown that not all patients with healthcare contact have equal risk for MDR organisms.

Study design: Prospective cohort study.

Setting: Japan, multi-center.

Synopsis: Of the 445 enrolled patients, 124 were diagnosed with community-acquired pneumonia (CAP) and 321 with HCAP. Patients with HCAP were classified based on severity of illness or MDR pathogen risk factors (immune suppression, hospitalization within the last 90 days, poor functional status, and antibiotics within the past six months). Patients with low risk (0-1 factors) for MDR organisms were treated for CAP, and patients with high risk (≥2 factors) or moderate risk (≥1 factor) for severe illness were treated for HCAP.

HCAP patients had a higher 30-day mortality rate (13.7% vs. 5.6%, P=0.017), but mortality rate was less in the patients at low risk for MDR pathogens (8.6% vs. 18.2%, P=0.012). Of the HCAP patients, only 7.1% received inappropriate therapy (pathogen resistant to initial antibiotic regimen), and treatment failure was 19.3%.

Appropriateness of initial empiric therapy was determined not to be a mortality risk; however, this trial might be limited by its location, because Japan appears to have fewer MDR pathogens than the U.S.

Bottom line: A treatment algorithm based on risk for MDR organisms and severity of illness can be used to guide empiric antibiotic therapy in patients with HCAP, and, ideally, to reduce excessive use of broad-spectrum antibiotics.

Citation: Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013;57(10):1373-1383.

Three-Month Dual Antiplatelet Therapy for Zotarolimus-Eluting Stents

Clinical question: Is short-term, dual antiplatelet therapy noninferior to long-term therapy in zotarolimus-eluting stents?

Background: Current guidelines recommend long-term (>12 months) dual antiplatelet therapy after the placement of drug-eluting stents. The optimal therapy duration in second-generation drug-eluting stents has not been studied; moreover, some studies with multiple drug-eluting stents have suggested no added benefit from long-term therapy.

Study design: Randomized controlled trial.

Setting: Brazil, multi-center.

Synopsis: Researchers randomized 3,211 patients with stable coronary artery disease (CAD) or low-risk acute coronary syndrome (ACS) undergoing intervention with zotarolimus-eluting stents to short-term (three months) or long-term (12 months) dual antiplatelet therapy. Exclusion criteria included ST-elevation myocardial infarction (STEMI), previous drug-eluting stent, scheduled elective surgery within 12 months, or contraindication to aspirin or clopidogrel. Primary endpoints were a composite of death from any cause, MI, stroke, or major bleeding. Secondary endpoints were stent thrombosis, target lesion revascularization, adverse cardiac event, and any bleed.

At one-year follow-up, the short-term group had similar primary (6.0% vs. 5.8%) and secondary (8.3% vs. 7.4%) outcomes compared to the long-term. The short-term group’s noninferiority also was seen in several key subgroups.

This study included patients with stable CAD or low-risk ACS and cannot be generalized to higher-risk patients. Results for zotarolimus-eluting stents cannot be generalized to other second-generation drug-eluting stents.

Bottom line: Zotarolimus-eluting stents, followed by three months of dual antiplatelet therapy, were noninferior to 12 months of therapy in patients with stable CAD or low-risk ACS.

Citation: Feres F, Costa RA, Abizaid A, et al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-2522.

De-Escalating Antibiotics in Sepsis

Clinical question: Does tailoring antibiotics based on known pathogens impact mortality for patients with severe sepsis or shock?

Background: In patients with sepsis, the use of early empiric antibiotics reduces morbidity and mortality. De-escalation therapy refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known; however, no randomized controlled studies have assessed the impact of this therapy on critically ill patients.

Study design: Prospective observational study.

Setting: Academic hospital ICU in Spain.

Synopsis: From January 2008 to May 2012, 628 adult patients were treated empirically with broad-spectrum antibiotics. De-escalation was applied to 219 patients (34.9%). Outcomes measured were ICU mortality, hospital mortality, and 90-day mortality in patients who received de-escalation therapy, patients whose antibiotics were not changed, and patients for whom antibiotics were escalated.

The in-hospital mortality rate was 27.4% in patients who were de-escalated, 32.6% in the unchanged group, and 42.9% in the escalation group. ICU and 90-day mortality were lower in the de-escalation group. De-escalation was more commonly used in medical than in surgical patients.

This study is limited because it is not a randomized controlled study and was single-centered, so it might only be applicable on the larger scale. Also, multi-drug resistant organisms were not evaluated.

Overall, it is safe to narrow empiric antibiotics in severe sepsis and shock when the pathogen and sensitivities are known.

Bottom line: De-escalation of antibiotics in severe sepsis and septic shock is associated with a lower mortality.

Citation: Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40.

New Oral Anticoagulants Increase GI Bleed Risk

Clinical question: Do thrombin and factor Xa inhibitors increase the risk of gastrointestinal (GI) bleeding when compared to vitamin K antagonists and heparins?

Background: New oral anticoagulants (thrombin and factor Xa inhibitors) are available and being used with increased frequency due to equal efficacy and ease of administration. Some studies indicate a higher risk of GI bleeding with these agents. Further evaluation is needed, because no reversal therapy is available.

Study design: Systematic review and meta-analysis.

Setting: Data from MEDLINE, Embase, and the Cochrane Library.

Synopsis: More than 150,000 patients from 43 randomized controlled trials were evaluated for risk of GI bleed when treated with new anticoagulants versus traditional therapy. Patients were treated for one of the following: embolism prevention from atrial fibrillation, venous thromboembolism (VTE) prophylaxis post orthopedic surgery, VTE prophylaxis of medical patients, acute VTE, and acute coronary syndrome (ACS). Use of aspirin or NSAIDs was discouraged but not documented. The odds ratio for GI bleeding with use of the new anticoagulants was 1.45, with a number needed to harm of 500. Evaluation of subgroups revealed increased GI bleed risk in patients treated for ACS and acute thrombosis versus prophylaxis. Post-surgical patients had the lowest risk.

This study was limited by the heterogeneity and differing primary outcomes (mostly efficacy rather than safety) of the included trials. Studies excluded high-risk patients, which the authors estimate to be 25%-40% of actual patients. More studies need to be done that include high-risk patients and focus on GI bleed as a primary outcome.

Bottom line: The new anticoagulants tend to have a higher incidence of GI bleed than traditional therapy, but this varies based on indication of therapy and needs further evaluation to clarify risk.

Citation: Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.

Single vs. Dual Antiplatelet Therapy after Stroke

Clinical question: Is dual antiplatelet therapy more beneficial or harmful than monotherapy after ischemic stroke?

Background: It is recommended that patients with ischemic stroke or transient ischemic attack (TIA) receive lifelong antiplatelet therapy; however, there have been insufficient studies evaluating the long-term safety of dual antiplatelet therapy.

Study design: Meta-analysis of randomized controlled trials (RCTs)

Setting: Data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Synopsis: Data from seven RCTs, including 39,574 patients with recent TIA or ischemic stroke, were reviewed. Comparisons were made regarding occurrence of intracranial hemorrhage (ICH) and recurrent stroke between patients receiving dual antiplatelet therapy and those receiving aspirin or clopidogrel monotherapy. All patients were treated for at least one year.

There was no difference in recurrent stroke or ICH between patients on dual antiplatelet therapy versus aspirin monotherapy. Patients treated with dual antiplatelet therapy did have a 46% increased risk of ICH without any additional protective benefit for recurrent stroke or TIA when compared with patients on clopidogrel monotherapy.

This information should not be applied in the acute setting, given the high risk of stroke after TIA or ischemic stroke. One major limitation of this study was that the individual trials used different combinations of dual antiplatelet therapy.

Bottom line: The risk of recurrent stroke or TIA after dual antiplatelet therapy and after monotherapy with aspirin or clopidogrel is equal, but the risk of ICH compared to clopidogrel monotherapy is increased.

Citation: Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis. Ann Intern Med. 2013;159(7):463-470.

Endoscopic vs. Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage

Clinical question: How does endoscopic cystogastrostomy for pancreatic pseudocyst drainage compare to the standard surgical approach?

Background: Pancreatic pseudocysts are a common complication of pancreatitis and necessitate decompression when they are accompanied by pain, infection, or obstruction. Decompression of the pseudocyst can be accomplished using either endoscopic or surgical cystogastrostomy.

Study design: Open-label, single-center, randomized trial.

Setting: Single-center U.S. hospital.

Synopsis: A total of 40 patients were randomly equalized to both treatment arms; 20 patients underwent endoscopic and 20 patients underwent surgical cystogastrostomy. Zero patients in the endoscopic therapy had a pseudocyst recurrence, compared with one patient treated surgically. Length of stay (LOS) and cost were lower for the endoscopic group compared to the surgical group (two days vs. six days, P<0.001, $7,011 vs. $15,052, P=0.003).

This study is limited due to several factors. First, patients with pancreatic necrosis were excluded; had these patients been included, the complication rates and LOS would have been higher. Second, cost difference cannot be generalized across the U.S., because Medicare payments are based on provider types and regions.

Bottom line: Endoscopic cystogastrostomy for pancreatic pseudocyst is equal to the standard surgical therapy and results in decreased LOS and reduced costs.

Citation: Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583-590.

Long-Term Cognitive Impairment after Critical Illness

Clinical question: Are a longer duration of delirium and higher doses of sedatives associated with cognitive impairment in the hospital?

Background: Survivors of critical illness are at risk for prolonged cognitive dysfunction. Delirium (and factors associated with delirium, namely sedative and analgesic medications) has been implicated in cognitive dysfunction.

Study design: Prospective cohort study.

Setting: Multi-center, academic, and acute care hospitals.

Synopsis: The study examined 821 adults admitted to the ICU with respiratory failure, cardiogenic shock, or septic shock. Patients excluded were those with pre-existing cognitive impairment, those with psychotic disorders, and those for whom follow-up would not be possible. Two risk factors measured were duration of delirium and use of sedative/analgesics. Delirium was assessed at three and 12 months using the CAM-ICU algorithm in the ICU by trained psychology professionals who were unaware of the patients’ in-hospital course.

At three months, 40% of patients had global cognition scores that were 1.5 standard deviations (SD) below population mean (similar to traumatic brain injury), and 26% had scores two SD below population mean (similar to mild Alzheimer’s). At 12 months, 34% had scores similar to traumatic brain injury patients, and 24% had scores similar to mild Alzheimer’s. A longer duration of delirium was associated with worse global cognition at three and 12 months. Use of sedatives/analgesics was not associated with cognitive impairment.

Bottom line: Critically ill patients in the ICU who experience a longer duration of delirium are at risk of long-term cognitive impairments lasting 12 months.

Citation: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.

Holding Chambers (Spacers) vs. Nebulizers for Acute Asthma

Clinical question: Are beta-2 agonists as effective when administered through a holding chamber (spacer) as they are when administered by a nebulizer?

Background: During an acute asthma attack, beta-2 agonists must be delivered to the peripheral airways. There has been considerable controversy regarding the use of a spacer compared with a nebulizer. Aside from admission rates and length of stay, factors taken into account include cost, maintenance of nebulizer machines, and infection control (potential of cross-infection via nebulizers).

Study design: Meta-analysis review of randomized controlled trials (RCTs).

Setting: Multi-centered, worldwide studies from community setting and EDs.

Synopsis: In 39 studies of patients with an acute asthma attack (selected from Cochrane Airways Group Specialized Register), the hospital admission rates did not differ on the basis of delivery method in 729 adults (risk ratio=0.94, confidence interval 0.61-1.43) or in 1,897 children (risk ratio=0.71, confidence interval 0.47-1.08). Secondary outcomes included the duration of time in the ED and the duration of hospital admission. Time spent in the ED varied for adults but was shorter for children with spacers (based on three studies). Duration of hospital admission also did not differ when modes of delivery were compared.

Bottom line: Providing beta-2 agonists using nebulizers during an acute asthma attack is not more effective than administration using a spacer.

Citation: Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.

Western medicine has a long tradition of humanitarian service in developing countries. But, over the past two decades, the manner in which medical services are provided to under-resourced nations has evolved. Rather than volunteering to deliver acute care through humanitarian missions, a new generation of global health physicians aims to become dispensable. Through new nonprofit and collaborative models, they are establishing ongoing relationships with medical professionals in host countries to actively promote capacity building, from construction of new facilities to medical education and training.

“Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting,” says HealthPartners hospitalist Brett R. Hendel-Paterson, MD, an assistant professor of medicine at the University of Minnesota who also practices in HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., and is co-director of the UM/CDC online global health course.

Sriram Shamasunder, MD, DTM&H, hospitalist, health sciences assistant clinical professor, and co-director of the University of California San Francisco (UCSF) Global Health-Hospital Medicine Fellowship, agrees. “Mission medicine has incredibly well-meaning and committed people, but to address the upstream problems that bring people to the hospital, there need to be systems-based solutions,” he says.

And that is where hospitalists come in.

Growing numbers of hospitalists are joining in global health efforts, as Marwa Shoeb, MD, MS, and Phuoc Le, MD, MPH, DTM&H, discovered when they surveyed SHM members about participation in global health activities. Drs. Shoeb and Le are assistant clinical professors in the division of hospital medicine at UCSF. The survey (J Hosp Med. 2013;8(13):162-163) revealed that 51% of 232 respondents had done global health work prior to becoming a hospitalist; another third continued global health work after they began their HM careers.

Many believe hospitalists are uniquely qualified for global health initiatives. HM’s emphasis on systems of care delivery and quality improvement can supply much-needed knowledge as under-resourced countries strive to increase access to health care, says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School in Boston and deputy chief medical officer of Partners in Health (PIH) in Haiti (www.pih.org).

“Being a hospitalist is incredibly complementary to doing global health work,” Dr. Morse says. PIH has maintained a presence in Haiti for more than two decades and just recently celebrated a milestone with the Haitian medical community: establishment of the country’s newest medical residency training at University Hospital in Mirebalais.

Embrace Challenges

In early December, a group of UCSF hospitalists visited another PIH site, a Haitian Ministry of Health hospital in Hinche, located in the central plateau region of the country. Robin Tittle, MD, and Varun Verma, MD, were nearing the end of their first three-month rotation in the country as clinical fellows in the two-year-old Global Health-Hospital Medicine Fellowship.

According to Dr. Tittle, working in a resource-challenged hospital such as the one in Hinche is an irreplaceable experience. She and Dr. Verma discovered new levels of meaning in the term “workaround.” For example, “we have really limited lab capacity,” Dr. Tittle says. “One interesting thing I learned is how much your lab depends on access to reliable electricity. A number of our machines have been ruined because of electrical power surges. There are only certain people in the lab who know how to run certain tests.”

Dr. Tittle has learned that “you can’t practice medicine [in Haiti] without addressing the system.” Exposure to QI methods during training have been useful, she says, as she and Dr. Verma designed a medical education seminar for their Haitian colleagues by identifying the top 10 diagnoses in the nursing discharge registry. Still, she admits that the effort was hampered by nonspecific diagnoses—again a result of their inability to run diagnostic tests.

The learning has been reciprocal, notes Dr. Jacquelin Pierre Auguste, one of the Haitian internists in Hinche.

“We share a lot of knowledge,” he says, enthusiastically.

One example Dr. Pierre shared was being able to bring the clinical fellows into the case of a young mother who had developed postpartum cardiomyopathy. For unknown reasons, the condition is 10-20 times as common in Haiti as in the U.S., according to Dr. Le, who is co-director of the UCSF Global Health-Hospital Medicine Fellowship program. “Our fellows are also learning much more about the management of late-stage disease in tuberculosis and HIV,” he adds.

Several hospitalists have witnessed misappropriation of resources in global health projects, which can occur during emergency situations, such as in post-earthquake Haiti. For benefits to be sustainable, it’s best not to “charge in,” but to carefully assess the needs of the host setting. Although needs assessment should be handled by the sponsoring organization, hospitalists can contribute to this effort so that well-intentioned relief efforts do not cause unintended consequences, Dr. Hendel-Paterson says.

Hospitalists Unite

In the global health survey conducted in 2012, Drs. Shoeb and Le found that 46% of respondents were interested in collaborating with other hospitalists in order to increase their impact on health equity. In response to these and other observations about a need for mentorship, SHM established a Global Health and Human Rights Section, chaired by Drs. Shoeb and Le. They will be hosting a special global health forum at HM14 later this month in Las Vegas (www.hospitalmedicine2014.org).

The section goals are to:

• Provide a forum for like-minded hospitalists to share experiences and knowledge;
• Enhance the skill sets of hospitalists to apply their expertise in resource-poor settings; and
• Strengthen the capacity of local health systems through long-term collaborations and training in quality improvement.

Dr. Le, who has been affiliated with Partners in Health since his residency at Harvard Medical School, has spent time in sub-Saharan Africa as well as Haiti. He has been instrumental in advancing the HM global health agenda at UCSF and helped to organize the first national retreat on global health in HM last year. The program held its second annual retreat in February 2014.

Besides UCSF, two other global health fellowships are designed specifically for hospitalists: the University of Chicago Global Hospital Medicine Fellowship is headed by Evan Lyon, MD, an assistant professor of medicine in the section of hospital medicine in the UC Department of Medicine; the University of Florida College of Medicine’s Global Health-Hospitalist Fellowship program in Gainesville is headed by Vincent DeGennaro, Jr., MD, MPH, assistant professor in the division of hospital medicine.

In addition, hospitalist Deepak Asudani, MD, MPH, FHM, health sciences assistant clinical professor at the University of California San Diego, reports that his department is interested in organizing a global health fellowship program. A firm believer in the distinction between global health and international health, Dr. Asudani explains that the UCSD program will be geared to teach U.S.-trained physicians how to practice medicine in resource-limited countries. It will have a track for physicians from other countries to study hospital medicine here.

Sustainable Care

During their rotations in Haiti, Dr. Le says the UCSF clinical fellows’ mission is capacity building, meaning they usually do not deliver care as primary physicians but rather engage in what he calls “clinical accompaniment.” They assist with care delivery and teach clinical skills to Haitian trainees.

“We do not want to be a substitute for doctors who are there,” he says. “We want to support Haitian residents and give consultative advice on difficult cases. We do not want to go, provide care, and leave. We are moving toward long-term relationships that foster systemic change.”

Clinical fellows teach quality improvement methods, and then the local partners, whether in Liberia or Haiti, generate ideas for QI projects around their most pressing needs. The fellows then offer support in the development and implementation of those projects.

Congruent Practice

The global health program at the University of Minnesota, led by Patricia Walker, MD, DTM&H, has established a medical teaching collaboration with Selian Lutheran Hospital in Arusha, Tanzania. Its name, Tufundishane, is a Swahili word meaning “let us all teach one another” and points out one of the many benefits for hospitalists who pursue this type of work. They report that the work changes the way they practice when they resume clinical duties back home.

Dr. Verma, a UCSF clinical fellow, can attest to those changes. After a three-month stint at St. Thérèse Hospital in Hinche, Dr. Verma says he intended to challenge his residents on the teaching service to “think about every single test they’re ordering.” That resolve was just one consequence of working in a resource-challenged hospital environment.

Speaking from Hinche in December, Dr. Verma says that in the U.S., “you can order a complete blood count and electrolytes for your patients every day they’re in the hospital. But here, if I want to get a renal test on a patient, I have to find the lab manager and find out if we have the reagents for those tests. It makes me question whether I really need that test or whether I am ordering it to make myself feel better.”

Dr. Verma views the workaround challenges as a net positive.

“Many times, you can do a lot of good for patients with an incomplete picture,” he says. It’s a view shared by other hospitalists who incorporate global health work into their clinical duties back in the U.S.

Dr. Hendel-Paterson has a wealth of global health experience: He worked in India and Zimbabwe during medical school, conducted research in Uganda, volunteered in Haiti, and has taught a tropical medicine course in Thailand. He says hospitalists can benefit from knowledge about global health when treating their own patients. For example, seeing patients with malaria or dengue fever during volunteer or service work can help providers recognize, diagnose, and treat those diseases in returning U.S. travelers. It also can help hospitalists avoid causing iatrogenic disease, as in the case of disseminated strongyloidiasis, which can result when people who have lived in or visited endemic areas are treated with immunosuppressants like corticosteroids.

Even if the experience does not give enough expertise to diagnose and treat, he says it can help providers realize that they should be asking for more testing or consultation in appropriate settings.

Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting.

—Brett R. Hendel-Paterson, MD, assistant professor of medicine, University of Minnesota, hospitalist, HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., co-director, UM/CDC online global health course.

Expand Your Thinking

Global health hospitalists interviewed by The Hospitalist believe good medicine is not tied to any particular place. Many find that work in other countries enriches their own core competencies as physicians.

As partnerships between health systems in other countries and the U.S. continue to grow, leaders hope the exchange will bring improvements for all parties. Dr. Shamasunder points out that as the healthcare dollar becomes scarcer in the U.S., those who work abroad might have much to contribute to the systems they work.

For Dr. Shamasunder and his colleagues, global health is not just about making people’s lives better but is also about taking into consideration the social determinants of health. What becomes clear after doing this work, he says, is that resource-challenged environments are everywhere and that patients’ social histories are relevant no matter the locale.

“If you simply treat a patient who has anemia from lead exposure, and you have no mechanism to address the presence of that toxin in their substandard housing, that patient may end up with lead poisoning,” he says.

As Dr. Hendel-Paterson sums it up: “There is no such thing as healthcare over here and healthcare over there.” That’s why he and other global health hospitalists are convinced that “global is local.”

Gretchen Henkel is a freelance writer in southern California.

Western medicine has a long tradition of humanitarian service in developing countries. But, over the past two decades, the manner in which medical services are provided to under-resourced nations has evolved. Rather than volunteering to deliver acute care through humanitarian missions, a new generation of global health physicians aims to become dispensable. Through new nonprofit and collaborative models, they are establishing ongoing relationships with medical professionals in host countries to actively promote capacity building, from construction of new facilities to medical education and training.

“Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting,” says HealthPartners hospitalist Brett R. Hendel-Paterson, MD, an assistant professor of medicine at the University of Minnesota who also practices in HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., and is co-director of the UM/CDC online global health course.

Sriram Shamasunder, MD, DTM&H, hospitalist, health sciences assistant clinical professor, and co-director of the University of California San Francisco (UCSF) Global Health-Hospital Medicine Fellowship, agrees. “Mission medicine has incredibly well-meaning and committed people, but to address the upstream problems that bring people to the hospital, there need to be systems-based solutions,” he says.

And that is where hospitalists come in.

Growing numbers of hospitalists are joining in global health efforts, as Marwa Shoeb, MD, MS, and Phuoc Le, MD, MPH, DTM&H, discovered when they surveyed SHM members about participation in global health activities. Drs. Shoeb and Le are assistant clinical professors in the division of hospital medicine at UCSF. The survey (J Hosp Med. 2013;8(13):162-163) revealed that 51% of 232 respondents had done global health work prior to becoming a hospitalist; another third continued global health work after they began their HM careers.

Many believe hospitalists are uniquely qualified for global health initiatives. HM’s emphasis on systems of care delivery and quality improvement can supply much-needed knowledge as under-resourced countries strive to increase access to health care, says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School in Boston and deputy chief medical officer of Partners in Health (PIH) in Haiti (www.pih.org).

“Being a hospitalist is incredibly complementary to doing global health work,” Dr. Morse says. PIH has maintained a presence in Haiti for more than two decades and just recently celebrated a milestone with the Haitian medical community: establishment of the country’s newest medical residency training at University Hospital in Mirebalais.

Embrace Challenges

In early December, a group of UCSF hospitalists visited another PIH site, a Haitian Ministry of Health hospital in Hinche, located in the central plateau region of the country. Robin Tittle, MD, and Varun Verma, MD, were nearing the end of their first three-month rotation in the country as clinical fellows in the two-year-old Global Health-Hospital Medicine Fellowship.

According to Dr. Tittle, working in a resource-challenged hospital such as the one in Hinche is an irreplaceable experience. She and Dr. Verma discovered new levels of meaning in the term “workaround.” For example, “we have really limited lab capacity,” Dr. Tittle says. “One interesting thing I learned is how much your lab depends on access to reliable electricity. A number of our machines have been ruined because of electrical power surges. There are only certain people in the lab who know how to run certain tests.”

Dr. Tittle has learned that “you can’t practice medicine [in Haiti] without addressing the system.” Exposure to QI methods during training have been useful, she says, as she and Dr. Verma designed a medical education seminar for their Haitian colleagues by identifying the top 10 diagnoses in the nursing discharge registry. Still, she admits that the effort was hampered by nonspecific diagnoses—again a result of their inability to run diagnostic tests.

The learning has been reciprocal, notes Dr. Jacquelin Pierre Auguste, one of the Haitian internists in Hinche.

“We share a lot of knowledge,” he says, enthusiastically.

One example Dr. Pierre shared was being able to bring the clinical fellows into the case of a young mother who had developed postpartum cardiomyopathy. For unknown reasons, the condition is 10-20 times as common in Haiti as in the U.S., according to Dr. Le, who is co-director of the UCSF Global Health-Hospital Medicine Fellowship program. “Our fellows are also learning much more about the management of late-stage disease in tuberculosis and HIV,” he adds.

Several hospitalists have witnessed misappropriation of resources in global health projects, which can occur during emergency situations, such as in post-earthquake Haiti. For benefits to be sustainable, it’s best not to “charge in,” but to carefully assess the needs of the host setting. Although needs assessment should be handled by the sponsoring organization, hospitalists can contribute to this effort so that well-intentioned relief efforts do not cause unintended consequences, Dr. Hendel-Paterson says.

Hospitalists Unite

In the global health survey conducted in 2012, Drs. Shoeb and Le found that 46% of respondents were interested in collaborating with other hospitalists in order to increase their impact on health equity. In response to these and other observations about a need for mentorship, SHM established a Global Health and Human Rights Section, chaired by Drs. Shoeb and Le. They will be hosting a special global health forum at HM14 later this month in Las Vegas (www.hospitalmedicine2014.org).

The section goals are to:

• Provide a forum for like-minded hospitalists to share experiences and knowledge;
• Enhance the skill sets of hospitalists to apply their expertise in resource-poor settings; and
• Strengthen the capacity of local health systems through long-term collaborations and training in quality improvement.

Dr. Le, who has been affiliated with Partners in Health since his residency at Harvard Medical School, has spent time in sub-Saharan Africa as well as Haiti. He has been instrumental in advancing the HM global health agenda at UCSF and helped to organize the first national retreat on global health in HM last year. The program held its second annual retreat in February 2014.

Besides UCSF, two other global health fellowships are designed specifically for hospitalists: the University of Chicago Global Hospital Medicine Fellowship is headed by Evan Lyon, MD, an assistant professor of medicine in the section of hospital medicine in the UC Department of Medicine; the University of Florida College of Medicine’s Global Health-Hospitalist Fellowship program in Gainesville is headed by Vincent DeGennaro, Jr., MD, MPH, assistant professor in the division of hospital medicine.

In addition, hospitalist Deepak Asudani, MD, MPH, FHM, health sciences assistant clinical professor at the University of California San Diego, reports that his department is interested in organizing a global health fellowship program. A firm believer in the distinction between global health and international health, Dr. Asudani explains that the UCSD program will be geared to teach U.S.-trained physicians how to practice medicine in resource-limited countries. It will have a track for physicians from other countries to study hospital medicine here.

Sustainable Care

During their rotations in Haiti, Dr. Le says the UCSF clinical fellows’ mission is capacity building, meaning they usually do not deliver care as primary physicians but rather engage in what he calls “clinical accompaniment.” They assist with care delivery and teach clinical skills to Haitian trainees.

“We do not want to be a substitute for doctors who are there,” he says. “We want to support Haitian residents and give consultative advice on difficult cases. We do not want to go, provide care, and leave. We are moving toward long-term relationships that foster systemic change.”

Clinical fellows teach quality improvement methods, and then the local partners, whether in Liberia or Haiti, generate ideas for QI projects around their most pressing needs. The fellows then offer support in the development and implementation of those projects.

Congruent Practice

The global health program at the University of Minnesota, led by Patricia Walker, MD, DTM&H, has established a medical teaching collaboration with Selian Lutheran Hospital in Arusha, Tanzania. Its name, Tufundishane, is a Swahili word meaning “let us all teach one another” and points out one of the many benefits for hospitalists who pursue this type of work. They report that the work changes the way they practice when they resume clinical duties back home.

Dr. Verma, a UCSF clinical fellow, can attest to those changes. After a three-month stint at St. Thérèse Hospital in Hinche, Dr. Verma says he intended to challenge his residents on the teaching service to “think about every single test they’re ordering.” That resolve was just one consequence of working in a resource-challenged hospital environment.

Speaking from Hinche in December, Dr. Verma says that in the U.S., “you can order a complete blood count and electrolytes for your patients every day they’re in the hospital. But here, if I want to get a renal test on a patient, I have to find the lab manager and find out if we have the reagents for those tests. It makes me question whether I really need that test or whether I am ordering it to make myself feel better.”

Dr. Verma views the workaround challenges as a net positive.

“Many times, you can do a lot of good for patients with an incomplete picture,” he says. It’s a view shared by other hospitalists who incorporate global health work into their clinical duties back in the U.S.

Dr. Hendel-Paterson has a wealth of global health experience: He worked in India and Zimbabwe during medical school, conducted research in Uganda, volunteered in Haiti, and has taught a tropical medicine course in Thailand. He says hospitalists can benefit from knowledge about global health when treating their own patients. For example, seeing patients with malaria or dengue fever during volunteer or service work can help providers recognize, diagnose, and treat those diseases in returning U.S. travelers. It also can help hospitalists avoid causing iatrogenic disease, as in the case of disseminated strongyloidiasis, which can result when people who have lived in or visited endemic areas are treated with immunosuppressants like corticosteroids.

Even if the experience does not give enough expertise to diagnose and treat, he says it can help providers realize that they should be asking for more testing or consultation in appropriate settings.

Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting.

—Brett R. Hendel-Paterson, MD, assistant professor of medicine, University of Minnesota, hospitalist, HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., co-director, UM/CDC online global health course.

Expand Your Thinking

Global health hospitalists interviewed by The Hospitalist believe good medicine is not tied to any particular place. Many find that work in other countries enriches their own core competencies as physicians.

As partnerships between health systems in other countries and the U.S. continue to grow, leaders hope the exchange will bring improvements for all parties. Dr. Shamasunder points out that as the healthcare dollar becomes scarcer in the U.S., those who work abroad might have much to contribute to the systems they work.

For Dr. Shamasunder and his colleagues, global health is not just about making people’s lives better but is also about taking into consideration the social determinants of health. What becomes clear after doing this work, he says, is that resource-challenged environments are everywhere and that patients’ social histories are relevant no matter the locale.

“If you simply treat a patient who has anemia from lead exposure, and you have no mechanism to address the presence of that toxin in their substandard housing, that patient may end up with lead poisoning,” he says.

As Dr. Hendel-Paterson sums it up: “There is no such thing as healthcare over here and healthcare over there.” That’s why he and other global health hospitalists are convinced that “global is local.”

Gretchen Henkel is a freelance writer in southern California.

Western medicine has a long tradition of humanitarian service in developing countries. But, over the past two decades, the manner in which medical services are provided to under-resourced nations has evolved. Rather than volunteering to deliver acute care through humanitarian missions, a new generation of global health physicians aims to become dispensable. Through new nonprofit and collaborative models, they are establishing ongoing relationships with medical professionals in host countries to actively promote capacity building, from construction of new facilities to medical education and training.

“Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting,” says HealthPartners hospitalist Brett R. Hendel-Paterson, MD, an assistant professor of medicine at the University of Minnesota who also practices in HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., and is co-director of the UM/CDC online global health course.

Sriram Shamasunder, MD, DTM&H, hospitalist, health sciences assistant clinical professor, and co-director of the University of California San Francisco (UCSF) Global Health-Hospital Medicine Fellowship, agrees. “Mission medicine has incredibly well-meaning and committed people, but to address the upstream problems that bring people to the hospital, there need to be systems-based solutions,” he says.

And that is where hospitalists come in.

Growing numbers of hospitalists are joining in global health efforts, as Marwa Shoeb, MD, MS, and Phuoc Le, MD, MPH, DTM&H, discovered when they surveyed SHM members about participation in global health activities. Drs. Shoeb and Le are assistant clinical professors in the division of hospital medicine at UCSF. The survey (J Hosp Med. 2013;8(13):162-163) revealed that 51% of 232 respondents had done global health work prior to becoming a hospitalist; another third continued global health work after they began their HM careers.

Many believe hospitalists are uniquely qualified for global health initiatives. HM’s emphasis on systems of care delivery and quality improvement can supply much-needed knowledge as under-resourced countries strive to increase access to health care, says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School in Boston and deputy chief medical officer of Partners in Health (PIH) in Haiti (www.pih.org).

“Being a hospitalist is incredibly complementary to doing global health work,” Dr. Morse says. PIH has maintained a presence in Haiti for more than two decades and just recently celebrated a milestone with the Haitian medical community: establishment of the country’s newest medical residency training at University Hospital in Mirebalais.

Embrace Challenges

In early December, a group of UCSF hospitalists visited another PIH site, a Haitian Ministry of Health hospital in Hinche, located in the central plateau region of the country. Robin Tittle, MD, and Varun Verma, MD, were nearing the end of their first three-month rotation in the country as clinical fellows in the two-year-old Global Health-Hospital Medicine Fellowship.

According to Dr. Tittle, working in a resource-challenged hospital such as the one in Hinche is an irreplaceable experience. She and Dr. Verma discovered new levels of meaning in the term “workaround.” For example, “we have really limited lab capacity,” Dr. Tittle says. “One interesting thing I learned is how much your lab depends on access to reliable electricity. A number of our machines have been ruined because of electrical power surges. There are only certain people in the lab who know how to run certain tests.”

Dr. Tittle has learned that “you can’t practice medicine [in Haiti] without addressing the system.” Exposure to QI methods during training have been useful, she says, as she and Dr. Verma designed a medical education seminar for their Haitian colleagues by identifying the top 10 diagnoses in the nursing discharge registry. Still, she admits that the effort was hampered by nonspecific diagnoses—again a result of their inability to run diagnostic tests.

The learning has been reciprocal, notes Dr. Jacquelin Pierre Auguste, one of the Haitian internists in Hinche.

“We share a lot of knowledge,” he says, enthusiastically.

One example Dr. Pierre shared was being able to bring the clinical fellows into the case of a young mother who had developed postpartum cardiomyopathy. For unknown reasons, the condition is 10-20 times as common in Haiti as in the U.S., according to Dr. Le, who is co-director of the UCSF Global Health-Hospital Medicine Fellowship program. “Our fellows are also learning much more about the management of late-stage disease in tuberculosis and HIV,” he adds.

Several hospitalists have witnessed misappropriation of resources in global health projects, which can occur during emergency situations, such as in post-earthquake Haiti. For benefits to be sustainable, it’s best not to “charge in,” but to carefully assess the needs of the host setting. Although needs assessment should be handled by the sponsoring organization, hospitalists can contribute to this effort so that well-intentioned relief efforts do not cause unintended consequences, Dr. Hendel-Paterson says.

Hospitalists Unite

In the global health survey conducted in 2012, Drs. Shoeb and Le found that 46% of respondents were interested in collaborating with other hospitalists in order to increase their impact on health equity. In response to these and other observations about a need for mentorship, SHM established a Global Health and Human Rights Section, chaired by Drs. Shoeb and Le. They will be hosting a special global health forum at HM14 later this month in Las Vegas (www.hospitalmedicine2014.org).

The section goals are to:

• Provide a forum for like-minded hospitalists to share experiences and knowledge;
• Enhance the skill sets of hospitalists to apply their expertise in resource-poor settings; and
• Strengthen the capacity of local health systems through long-term collaborations and training in quality improvement.

Dr. Le, who has been affiliated with Partners in Health since his residency at Harvard Medical School, has spent time in sub-Saharan Africa as well as Haiti. He has been instrumental in advancing the HM global health agenda at UCSF and helped to organize the first national retreat on global health in HM last year. The program held its second annual retreat in February 2014.

Besides UCSF, two other global health fellowships are designed specifically for hospitalists: the University of Chicago Global Hospital Medicine Fellowship is headed by Evan Lyon, MD, an assistant professor of medicine in the section of hospital medicine in the UC Department of Medicine; the University of Florida College of Medicine’s Global Health-Hospitalist Fellowship program in Gainesville is headed by Vincent DeGennaro, Jr., MD, MPH, assistant professor in the division of hospital medicine.

In addition, hospitalist Deepak Asudani, MD, MPH, FHM, health sciences assistant clinical professor at the University of California San Diego, reports that his department is interested in organizing a global health fellowship program. A firm believer in the distinction between global health and international health, Dr. Asudani explains that the UCSD program will be geared to teach U.S.-trained physicians how to practice medicine in resource-limited countries. It will have a track for physicians from other countries to study hospital medicine here.

Sustainable Care

During their rotations in Haiti, Dr. Le says the UCSF clinical fellows’ mission is capacity building, meaning they usually do not deliver care as primary physicians but rather engage in what he calls “clinical accompaniment.” They assist with care delivery and teach clinical skills to Haitian trainees.

“We do not want to be a substitute for doctors who are there,” he says. “We want to support Haitian residents and give consultative advice on difficult cases. We do not want to go, provide care, and leave. We are moving toward long-term relationships that foster systemic change.”

Clinical fellows teach quality improvement methods, and then the local partners, whether in Liberia or Haiti, generate ideas for QI projects around their most pressing needs. The fellows then offer support in the development and implementation of those projects.

Congruent Practice

The global health program at the University of Minnesota, led by Patricia Walker, MD, DTM&H, has established a medical teaching collaboration with Selian Lutheran Hospital in Arusha, Tanzania. Its name, Tufundishane, is a Swahili word meaning “let us all teach one another” and points out one of the many benefits for hospitalists who pursue this type of work. They report that the work changes the way they practice when they resume clinical duties back home.

Dr. Verma, a UCSF clinical fellow, can attest to those changes. After a three-month stint at St. Thérèse Hospital in Hinche, Dr. Verma says he intended to challenge his residents on the teaching service to “think about every single test they’re ordering.” That resolve was just one consequence of working in a resource-challenged hospital environment.

Speaking from Hinche in December, Dr. Verma says that in the U.S., “you can order a complete blood count and electrolytes for your patients every day they’re in the hospital. But here, if I want to get a renal test on a patient, I have to find the lab manager and find out if we have the reagents for those tests. It makes me question whether I really need that test or whether I am ordering it to make myself feel better.”

Dr. Verma views the workaround challenges as a net positive.

“Many times, you can do a lot of good for patients with an incomplete picture,” he says. It’s a view shared by other hospitalists who incorporate global health work into their clinical duties back in the U.S.

Dr. Hendel-Paterson has a wealth of global health experience: He worked in India and Zimbabwe during medical school, conducted research in Uganda, volunteered in Haiti, and has taught a tropical medicine course in Thailand. He says hospitalists can benefit from knowledge about global health when treating their own patients. For example, seeing patients with malaria or dengue fever during volunteer or service work can help providers recognize, diagnose, and treat those diseases in returning U.S. travelers. It also can help hospitalists avoid causing iatrogenic disease, as in the case of disseminated strongyloidiasis, which can result when people who have lived in or visited endemic areas are treated with immunosuppressants like corticosteroids.

Even if the experience does not give enough expertise to diagnose and treat, he says it can help providers realize that they should be asking for more testing or consultation in appropriate settings.

Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting.

—Brett R. Hendel-Paterson, MD, assistant professor of medicine, University of Minnesota, hospitalist, HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., co-director, UM/CDC online global health course.

Expand Your Thinking

Global health hospitalists interviewed by The Hospitalist believe good medicine is not tied to any particular place. Many find that work in other countries enriches their own core competencies as physicians.

As partnerships between health systems in other countries and the U.S. continue to grow, leaders hope the exchange will bring improvements for all parties. Dr. Shamasunder points out that as the healthcare dollar becomes scarcer in the U.S., those who work abroad might have much to contribute to the systems they work.

For Dr. Shamasunder and his colleagues, global health is not just about making people’s lives better but is also about taking into consideration the social determinants of health. What becomes clear after doing this work, he says, is that resource-challenged environments are everywhere and that patients’ social histories are relevant no matter the locale.

“If you simply treat a patient who has anemia from lead exposure, and you have no mechanism to address the presence of that toxin in their substandard housing, that patient may end up with lead poisoning,” he says.

As Dr. Hendel-Paterson sums it up: “There is no such thing as healthcare over here and healthcare over there.” That’s why he and other global health hospitalists are convinced that “global is local.”

Gretchen Henkel is a freelance writer in southern California.

Are you looking to improve your hospital medicine group (HMG)? Would you like to measure your group against other groups?

The February 2013 issue of the Journal of Hospital Medicine included a seminal article for our specialty, “The Key Principles and Characteristics of an Effective Hospital Medicine Group: an assessment guide for hospitals and hospitalists.” This paper has received a vast amount of attention around the country from hospitalists, hospitalist leaders, HMGs, and hospital executives. The report (www.hospitalmedicine.org/keychar) is a first step for physicians and executives looking to benchmark their practices, and it has stimulated discussions among many HMGs, beginning a process of self-review and considering action.

I am coming up on my 20th year as a hospitalist, and the debate over what makes a high-performing HMG has continued that entire time. In the beginning, there were questions about the mere existence of hospital medicine and HMGs. The discussion about what makes a high-performing HMG started among the physicians, medical groups, and hospitals that signed on early to the HM movement. At conferences, HMG leaders debated how to set up a program. A series of pioneer hospitalists, many with only a few years of experience, roamed the country as consultants giving advice on best practices. A professional society, the National Association of Inpatient Physicians, was born and, later, recast as the Society of Hospital Medicine (SHM)—and the discussion continued.

SHM furthered the debate with such important milestones as The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, white papers on career satisfaction and hospitalist involvement in quality/safety and transitions of care. Different types of practice arrangements developed. Some were hospital-based, some physician practice-centered. Some were local, and others were regional and national. Each of these spawned innovations in HMG processes and contributed to the growing body of best practices.

Over the past five years, a consensus regarding those best practices has seemingly developed, and the discussions are centered on fine details rather than significant differences. To that end, approximately three years ago, a small group of SHM members met and discussed how to capture this information and disseminate it better among hospitalists, HMGs, and hospitals. We had all come to a similar conclusion—high-performing HMGs share common characteristics. Furthermore, every hospital and HMG seeks excellence, striving to be the best that they can be. We settled on a plan to write this up.

After a year of debate, we sought SHM’s help in the development phase and, in early 2012, SHM’s board of directors appointed a workgroup to identify the key principles and characteristics of an effective HMG. The initial group was widened to make sure we included different backgrounds and experiences in hospital medicine. The group had a wide array of involvement in HMG models, including HMG members, HMG leaders, hospital executives, and some involved in consulting. Many of the individuals had multiple experiences. The conversation among these individuals was lively!

The workgroup developed an initial draft of characteristics, which then went through a multi-step process of review and redrafting. More than 200 individuals, representing a broad group of stakeholders in hospital medicine and in the healthcare industry in general, provided comments and feedback. In addition, the workgroup went through a two-step Delphi process to consolidate and/or eliminate characteristics that were redundant or unnecessary.

In the final framework, 47 key characteristics were defined and organized under 10 principles (see Figure 1).

The authors and SHM’s board of directors view this document as an aspirational approach to improvement. We feel it helps to “raise the bar” for the specialty of hospital medicine by laying out a roadmap of potential improvement. These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute care setting.

In enhancing quality, the approach of a gap analysis is a very effective tool. These principles provide an excellent approach to begin that review.

So how do you get started? Hopefully, your HMG has a regular meeting. Take a principle and have a conversation. For example, what do we have? What don’t we have?

Other groups may want to tackle the entire document in a daylong strategy review. Some may want an outside facilitator. Bottom line: It doesn’t matter how you do it; just start with a conversation.

Dr. Cawley is CEO of Medical University of South Carolina Medical Center in Charleston. He is past president of SHM.

Reference

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.

Are you looking to improve your hospital medicine group (HMG)? Would you like to measure your group against other groups?

The February 2013 issue of the Journal of Hospital Medicine included a seminal article for our specialty, “The Key Principles and Characteristics of an Effective Hospital Medicine Group: an assessment guide for hospitals and hospitalists.” This paper has received a vast amount of attention around the country from hospitalists, hospitalist leaders, HMGs, and hospital executives. The report (www.hospitalmedicine.org/keychar) is a first step for physicians and executives looking to benchmark their practices, and it has stimulated discussions among many HMGs, beginning a process of self-review and considering action.

I am coming up on my 20th year as a hospitalist, and the debate over what makes a high-performing HMG has continued that entire time. In the beginning, there were questions about the mere existence of hospital medicine and HMGs. The discussion about what makes a high-performing HMG started among the physicians, medical groups, and hospitals that signed on early to the HM movement. At conferences, HMG leaders debated how to set up a program. A series of pioneer hospitalists, many with only a few years of experience, roamed the country as consultants giving advice on best practices. A professional society, the National Association of Inpatient Physicians, was born and, later, recast as the Society of Hospital Medicine (SHM)—and the discussion continued.

SHM furthered the debate with such important milestones as The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, white papers on career satisfaction and hospitalist involvement in quality/safety and transitions of care. Different types of practice arrangements developed. Some were hospital-based, some physician practice-centered. Some were local, and others were regional and national. Each of these spawned innovations in HMG processes and contributed to the growing body of best practices.

Over the past five years, a consensus regarding those best practices has seemingly developed, and the discussions are centered on fine details rather than significant differences. To that end, approximately three years ago, a small group of SHM members met and discussed how to capture this information and disseminate it better among hospitalists, HMGs, and hospitals. We had all come to a similar conclusion—high-performing HMGs share common characteristics. Furthermore, every hospital and HMG seeks excellence, striving to be the best that they can be. We settled on a plan to write this up.

After a year of debate, we sought SHM’s help in the development phase and, in early 2012, SHM’s board of directors appointed a workgroup to identify the key principles and characteristics of an effective HMG. The initial group was widened to make sure we included different backgrounds and experiences in hospital medicine. The group had a wide array of involvement in HMG models, including HMG members, HMG leaders, hospital executives, and some involved in consulting. Many of the individuals had multiple experiences. The conversation among these individuals was lively!

The workgroup developed an initial draft of characteristics, which then went through a multi-step process of review and redrafting. More than 200 individuals, representing a broad group of stakeholders in hospital medicine and in the healthcare industry in general, provided comments and feedback. In addition, the workgroup went through a two-step Delphi process to consolidate and/or eliminate characteristics that were redundant or unnecessary.

In the final framework, 47 key characteristics were defined and organized under 10 principles (see Figure 1).

The authors and SHM’s board of directors view this document as an aspirational approach to improvement. We feel it helps to “raise the bar” for the specialty of hospital medicine by laying out a roadmap of potential improvement. These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute care setting.

In enhancing quality, the approach of a gap analysis is a very effective tool. These principles provide an excellent approach to begin that review.

So how do you get started? Hopefully, your HMG has a regular meeting. Take a principle and have a conversation. For example, what do we have? What don’t we have?

Other groups may want to tackle the entire document in a daylong strategy review. Some may want an outside facilitator. Bottom line: It doesn’t matter how you do it; just start with a conversation.

Dr. Cawley is CEO of Medical University of South Carolina Medical Center in Charleston. He is past president of SHM.

Reference

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.

Are you looking to improve your hospital medicine group (HMG)? Would you like to measure your group against other groups?

The February 2013 issue of the Journal of Hospital Medicine included a seminal article for our specialty, “The Key Principles and Characteristics of an Effective Hospital Medicine Group: an assessment guide for hospitals and hospitalists.” This paper has received a vast amount of attention around the country from hospitalists, hospitalist leaders, HMGs, and hospital executives. The report (www.hospitalmedicine.org/keychar) is a first step for physicians and executives looking to benchmark their practices, and it has stimulated discussions among many HMGs, beginning a process of self-review and considering action.

I am coming up on my 20th year as a hospitalist, and the debate over what makes a high-performing HMG has continued that entire time. In the beginning, there were questions about the mere existence of hospital medicine and HMGs. The discussion about what makes a high-performing HMG started among the physicians, medical groups, and hospitals that signed on early to the HM movement. At conferences, HMG leaders debated how to set up a program. A series of pioneer hospitalists, many with only a few years of experience, roamed the country as consultants giving advice on best practices. A professional society, the National Association of Inpatient Physicians, was born and, later, recast as the Society of Hospital Medicine (SHM)—and the discussion continued.

SHM furthered the debate with such important milestones as The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, white papers on career satisfaction and hospitalist involvement in quality/safety and transitions of care. Different types of practice arrangements developed. Some were hospital-based, some physician practice-centered. Some were local, and others were regional and national. Each of these spawned innovations in HMG processes and contributed to the growing body of best practices.

Over the past five years, a consensus regarding those best practices has seemingly developed, and the discussions are centered on fine details rather than significant differences. To that end, approximately three years ago, a small group of SHM members met and discussed how to capture this information and disseminate it better among hospitalists, HMGs, and hospitals. We had all come to a similar conclusion—high-performing HMGs share common characteristics. Furthermore, every hospital and HMG seeks excellence, striving to be the best that they can be. We settled on a plan to write this up.

After a year of debate, we sought SHM’s help in the development phase and, in early 2012, SHM’s board of directors appointed a workgroup to identify the key principles and characteristics of an effective HMG. The initial group was widened to make sure we included different backgrounds and experiences in hospital medicine. The group had a wide array of involvement in HMG models, including HMG members, HMG leaders, hospital executives, and some involved in consulting. Many of the individuals had multiple experiences. The conversation among these individuals was lively!

The workgroup developed an initial draft of characteristics, which then went through a multi-step process of review and redrafting. More than 200 individuals, representing a broad group of stakeholders in hospital medicine and in the healthcare industry in general, provided comments and feedback. In addition, the workgroup went through a two-step Delphi process to consolidate and/or eliminate characteristics that were redundant or unnecessary.

In the final framework, 47 key characteristics were defined and organized under 10 principles (see Figure 1).

The authors and SHM’s board of directors view this document as an aspirational approach to improvement. We feel it helps to “raise the bar” for the specialty of hospital medicine by laying out a roadmap of potential improvement. These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute care setting.

In enhancing quality, the approach of a gap analysis is a very effective tool. These principles provide an excellent approach to begin that review.

So how do you get started? Hopefully, your HMG has a regular meeting. Take a principle and have a conversation. For example, what do we have? What don’t we have?

Other groups may want to tackle the entire document in a daylong strategy review. Some may want an outside facilitator. Bottom line: It doesn’t matter how you do it; just start with a conversation.

Dr. Cawley is CEO of Medical University of South Carolina Medical Center in Charleston. He is past president of SHM.

Reference

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.

Dr. Scheurer

We talk a lot about value in healthcare—about how to enhance quality and reduce cost—because we all know both need an incredible amount of work. One tactic Medicare is using to improve the value equation on a large scale is aggregating and displaying physician-specific “value” metrics. These metrics, which will be used to deduct or enhance reimbursement for physicians, are known as the Physician Value-Based Payment Modifier (PVBM).

This program has been enacted fairly rapidly since the passage of the Affordable Care Act; it is being rolled out first to large physician practices, then to all groups by 2017. Those with superior performance in both quality and cost will experience as much as a 2% higher reimbursement, while groups with average performance will remain financially neutral and those who show lower performance or choose not to report will be penalized up to 1% of Medicare reimbursement. This first round, for larger groups of 100-plus physicians, will affect about 30% of all U.S. physicians. The second round, for groups of 10 or more physicians, will affect about another third of physicians. The last round, for groups with fewer than 10 physicians, will be applicable to the remaining physicians practicing in the U.S.

On the face of it, the program does seem to be a potentially effective tactic for improving value on a large scale, holding individual physicians accountable for their own individual patient-care performance. A few fatal flaws in the program as it currently stands make it extraordinarily unlikely to be universally adopted by all physicians, however. Here are a few of those flaws:^1,2

1 Uncertain yield: Because it is essentially a “zero-sum game” for Medicare, the incentive or penalty for a physician (or the physician’s group) depends on the performance of all the other physicians’ or groups’ performance. As a result, there is incredible uncertainty as to how strong a physician’s performance actually needs to be, year to year, to result in a bonus payment. Given that many of the metrics will require some type of investment to perform well, such as information technology infrastructure or a quality coordinator, there is an equal amount of uncertainty about how much investment will be needed to get a certain budgetary yield. For smaller physician practices, taking a 1% to 2% reduction in Medicare reimbursements may be easier to weather financially than investing in the infrastructure needed to reliably hit the quality metrics for every relevant patient.

2 Uncertain benchmarks: Unlike many hospital quality metrics, which have been publicly displayed for years, physician-level value metrics are just now being reported publicly. This leaves uncertainty about how strong a physician’s performance needs to be in order to be better than average. In the hospital value-based purchasing program, “average” performance is extremely good, in the 98% to 99% compliance range for most metrics. It is less clear what compliance range will be “average” in the physician-based program.

3 Physician variability: More than a half million physicians in the U.S. bill Medicare, and their practice types range from primary care solo practice to multi-group specialty practice. Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.

4 Metric identity and attribution: Because the repertoire of physician types is broad, the ability of each physician type to have a set of metrics that they understand and can identify with is extremely unlikely. In addition, attribution of patients and their associated metrics to any single physician is complicated, especially for patients who are cared for by many different physicians across a number of settings. For hospitalists, the attribution issue is a fatal flaw, as many groups routinely “hand off” patients among other hospitalists in their group, at least once if not several times during a typical hospital stay. The same is true of many other hospital-based specialty physicians.

5 Playing to the test: As with other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.

6 Reducing the risk: As seen in other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to avoid caring for patients who are likely to be unpredictable, including those with multiple co-morbid conditions or with complex social situations; these patients are likely to perform less well on any metric, despite risk adjusting (which is inherently imperfect). This is a well-known and documented risk of publicly reported programs, and there is no reason to believe the PVBM program will be immune to this risk.

In Sum

Because these flaws seem so daunting at first glance, many physicians and physician groups will be tempted to reject the program outright and take the financial hit induced by nonparticipation. An alternative approach is to embrace all of the value programs outright, investing time and energy in improving the metrics that are truly valuable to both patients and providers.

Regardless of which regulatory agency is demanding performance, we need to be active participants in foraging out what metrics and attribution logic are most appropriate. For hospitalists, these could include risk-adjusted device days, appropriate prescribing and unprescribing of antibiotics, judicious utilization of diagnostic testing, and measurements of patient functional status and/or mobility.

Value metrics are here to stay, including those attributable to individual physicians; our job now is to advocate for meaningful metrics and meaningful attribution, which can and should motivate hospitalists to enhance their patients’ quality of life at a lower cost.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Chien AT, Rosenthal MB. Medicare’s physician value based payment modifier—will the techtonic shift create waves? N Engl J Med. 2013;369(22):2076-2078.
2. Berenson RA, Kaye DR. Grading a physician’s value—the misapplication of performance measurement. N Engl J Med. 2013;369(22):2079-2081.

Dr. Scheurer

We talk a lot about value in healthcare—about how to enhance quality and reduce cost—because we all know both need an incredible amount of work. One tactic Medicare is using to improve the value equation on a large scale is aggregating and displaying physician-specific “value” metrics. These metrics, which will be used to deduct or enhance reimbursement for physicians, are known as the Physician Value-Based Payment Modifier (PVBM).

This program has been enacted fairly rapidly since the passage of the Affordable Care Act; it is being rolled out first to large physician practices, then to all groups by 2017. Those with superior performance in both quality and cost will experience as much as a 2% higher reimbursement, while groups with average performance will remain financially neutral and those who show lower performance or choose not to report will be penalized up to 1% of Medicare reimbursement. This first round, for larger groups of 100-plus physicians, will affect about 30% of all U.S. physicians. The second round, for groups of 10 or more physicians, will affect about another third of physicians. The last round, for groups with fewer than 10 physicians, will be applicable to the remaining physicians practicing in the U.S.

On the face of it, the program does seem to be a potentially effective tactic for improving value on a large scale, holding individual physicians accountable for their own individual patient-care performance. A few fatal flaws in the program as it currently stands make it extraordinarily unlikely to be universally adopted by all physicians, however. Here are a few of those flaws:^1,2

1 Uncertain yield: Because it is essentially a “zero-sum game” for Medicare, the incentive or penalty for a physician (or the physician’s group) depends on the performance of all the other physicians’ or groups’ performance. As a result, there is incredible uncertainty as to how strong a physician’s performance actually needs to be, year to year, to result in a bonus payment. Given that many of the metrics will require some type of investment to perform well, such as information technology infrastructure or a quality coordinator, there is an equal amount of uncertainty about how much investment will be needed to get a certain budgetary yield. For smaller physician practices, taking a 1% to 2% reduction in Medicare reimbursements may be easier to weather financially than investing in the infrastructure needed to reliably hit the quality metrics for every relevant patient.

2 Uncertain benchmarks: Unlike many hospital quality metrics, which have been publicly displayed for years, physician-level value metrics are just now being reported publicly. This leaves uncertainty about how strong a physician’s performance needs to be in order to be better than average. In the hospital value-based purchasing program, “average” performance is extremely good, in the 98% to 99% compliance range for most metrics. It is less clear what compliance range will be “average” in the physician-based program.

3 Physician variability: More than a half million physicians in the U.S. bill Medicare, and their practice types range from primary care solo practice to multi-group specialty practice. Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.

4 Metric identity and attribution: Because the repertoire of physician types is broad, the ability of each physician type to have a set of metrics that they understand and can identify with is extremely unlikely. In addition, attribution of patients and their associated metrics to any single physician is complicated, especially for patients who are cared for by many different physicians across a number of settings. For hospitalists, the attribution issue is a fatal flaw, as many groups routinely “hand off” patients among other hospitalists in their group, at least once if not several times during a typical hospital stay. The same is true of many other hospital-based specialty physicians.

5 Playing to the test: As with other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.

6 Reducing the risk: As seen in other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to avoid caring for patients who are likely to be unpredictable, including those with multiple co-morbid conditions or with complex social situations; these patients are likely to perform less well on any metric, despite risk adjusting (which is inherently imperfect). This is a well-known and documented risk of publicly reported programs, and there is no reason to believe the PVBM program will be immune to this risk.

In Sum

Because these flaws seem so daunting at first glance, many physicians and physician groups will be tempted to reject the program outright and take the financial hit induced by nonparticipation. An alternative approach is to embrace all of the value programs outright, investing time and energy in improving the metrics that are truly valuable to both patients and providers.

Regardless of which regulatory agency is demanding performance, we need to be active participants in foraging out what metrics and attribution logic are most appropriate. For hospitalists, these could include risk-adjusted device days, appropriate prescribing and unprescribing of antibiotics, judicious utilization of diagnostic testing, and measurements of patient functional status and/or mobility.

Value metrics are here to stay, including those attributable to individual physicians; our job now is to advocate for meaningful metrics and meaningful attribution, which can and should motivate hospitalists to enhance their patients’ quality of life at a lower cost.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Chien AT, Rosenthal MB. Medicare’s physician value based payment modifier—will the techtonic shift create waves? N Engl J Med. 2013;369(22):2076-2078.
2. Berenson RA, Kaye DR. Grading a physician’s value—the misapplication of performance measurement. N Engl J Med. 2013;369(22):2079-2081.

Dr. Scheurer

We talk a lot about value in healthcare—about how to enhance quality and reduce cost—because we all know both need an incredible amount of work. One tactic Medicare is using to improve the value equation on a large scale is aggregating and displaying physician-specific “value” metrics. These metrics, which will be used to deduct or enhance reimbursement for physicians, are known as the Physician Value-Based Payment Modifier (PVBM).

This program has been enacted fairly rapidly since the passage of the Affordable Care Act; it is being rolled out first to large physician practices, then to all groups by 2017. Those with superior performance in both quality and cost will experience as much as a 2% higher reimbursement, while groups with average performance will remain financially neutral and those who show lower performance or choose not to report will be penalized up to 1% of Medicare reimbursement. This first round, for larger groups of 100-plus physicians, will affect about 30% of all U.S. physicians. The second round, for groups of 10 or more physicians, will affect about another third of physicians. The last round, for groups with fewer than 10 physicians, will be applicable to the remaining physicians practicing in the U.S.

On the face of it, the program does seem to be a potentially effective tactic for improving value on a large scale, holding individual physicians accountable for their own individual patient-care performance. A few fatal flaws in the program as it currently stands make it extraordinarily unlikely to be universally adopted by all physicians, however. Here are a few of those flaws:^1,2

1 Uncertain yield: Because it is essentially a “zero-sum game” for Medicare, the incentive or penalty for a physician (or the physician’s group) depends on the performance of all the other physicians’ or groups’ performance. As a result, there is incredible uncertainty as to how strong a physician’s performance actually needs to be, year to year, to result in a bonus payment. Given that many of the metrics will require some type of investment to perform well, such as information technology infrastructure or a quality coordinator, there is an equal amount of uncertainty about how much investment will be needed to get a certain budgetary yield. For smaller physician practices, taking a 1% to 2% reduction in Medicare reimbursements may be easier to weather financially than investing in the infrastructure needed to reliably hit the quality metrics for every relevant patient.

2 Uncertain benchmarks: Unlike many hospital quality metrics, which have been publicly displayed for years, physician-level value metrics are just now being reported publicly. This leaves uncertainty about how strong a physician’s performance needs to be in order to be better than average. In the hospital value-based purchasing program, “average” performance is extremely good, in the 98% to 99% compliance range for most metrics. It is less clear what compliance range will be “average” in the physician-based program.

3 Physician variability: More than a half million physicians in the U.S. bill Medicare, and their practice types range from primary care solo practice to multi-group specialty practice. Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.

4 Metric identity and attribution: Because the repertoire of physician types is broad, the ability of each physician type to have a set of metrics that they understand and can identify with is extremely unlikely. In addition, attribution of patients and their associated metrics to any single physician is complicated, especially for patients who are cared for by many different physicians across a number of settings. For hospitalists, the attribution issue is a fatal flaw, as many groups routinely “hand off” patients among other hospitalists in their group, at least once if not several times during a typical hospital stay. The same is true of many other hospital-based specialty physicians.

5 Playing to the test: As with other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.

6 Reducing the risk: As seen in other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to avoid caring for patients who are likely to be unpredictable, including those with multiple co-morbid conditions or with complex social situations; these patients are likely to perform less well on any metric, despite risk adjusting (which is inherently imperfect). This is a well-known and documented risk of publicly reported programs, and there is no reason to believe the PVBM program will be immune to this risk.

In Sum

Because these flaws seem so daunting at first glance, many physicians and physician groups will be tempted to reject the program outright and take the financial hit induced by nonparticipation. An alternative approach is to embrace all of the value programs outright, investing time and energy in improving the metrics that are truly valuable to both patients and providers.

Regardless of which regulatory agency is demanding performance, we need to be active participants in foraging out what metrics and attribution logic are most appropriate. For hospitalists, these could include risk-adjusted device days, appropriate prescribing and unprescribing of antibiotics, judicious utilization of diagnostic testing, and measurements of patient functional status and/or mobility.

Value metrics are here to stay, including those attributable to individual physicians; our job now is to advocate for meaningful metrics and meaningful attribution, which can and should motivate hospitalists to enhance their patients’ quality of life at a lower cost.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Chien AT, Rosenthal MB. Medicare’s physician value based payment modifier—will the techtonic shift create waves? N Engl J Med. 2013;369(22):2076-2078.
2. Berenson RA, Kaye DR. Grading a physician’s value—the misapplication of performance measurement. N Engl J Med. 2013;369(22):2079-2081.

Are you attracted to research but not sure if it’s your sole calling as a prospective hospitalist? Whether you think you might want to steer quality improvement (QI) studies in the community setting or veer toward an academic/research career, hospital medicine offers an array of paths to career satisfaction.

“There is so much room in hospital medicine to find your research niche,” says Luci K. Leykum, MD, MBA, MSc, SFHM, hospital medicine division chief and associate dean for clinical affairs at University of Texas Health Science Center in San Antonio. As chair of SHM’s Research Committee, Dr. Leykum can attest to the range of hospitalists’ research pursuits: from basic science (what biomarkers best predict poor outcomes in patients with acute lung injury?) to care organization (are hospitalist schedules and workload associated with patient outcomes?) to implementation (how do we most effectively implement best practices for care transitions?) studies.^1-6

Dr. Leykum

In addition to Dr. Leykum, The Hospitalist consulted Vineet Arora, MD, MPP, FACP, SFHM, associate professor of medicine at the University of Chicago and chair of SHM’s Physicians in Training Committee, and Margaret Fang, MD, MPH, FHM, associate professor and clinician-investigator in the department of medicine at University of California San Francisco (UCSF) Medical Center and a member of the SHM Research Committee. Critical to research success, they agree, is acquiring skills in research methodology and project design, finding the right mentor(s) to help guide your career, and committing to and preserving time to focus on your research.

“After residency,” Dr. Arora notes, “you have accumulated the clinical skills to become a hospitalist, but you usually have not accumulated the skill it takes to be a researcher, which is why you need to do additional training.”

Is a Fellowship Necessary?

The paths to incorporating research into one’s HM career can be diverse. Although a fellowship is often the recommended route, there are other ways to acquire research methodology and experience with project design. Dr. Leykum began her career as a clinician-educator at Columbia University in New York. Although she found the QI work enjoyable, she realized she wanted to understand how to create more meaningful and sustainable changes in inpatient care delivery. She later acquired a master’s degree in clinical investigation. She has published more than 25 journal articles, several in collaboration with other SHM colleagues.

As a result, perhaps, of her own experience—and the fact that HM is still a young subspecialty with limited HM-specific fellowship opportunities—Dr. Leykum says that she would consider hiring a junior faculty member who had not yet completed a fellowship. “I think you have to consider people who might be talented candidates that you are willing to groom,” she says. However, she says she would structure the position so that the faculty member could immediately pursue additional research training.

“If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.”

–Dr. Fang

Dr. Fang completed a two-year, general medical research fellowship right after her residency and obtained her master of public health degree at that time. “I do agree,” she says, “that the fastest way to doing research well is to get some additional training.”

Even if you are not aiming to become a full-time investigator, Dr. Arora says a research fellowship “gives you very marketable skills. You will still gain skills that will be helpful to your career—and not all research is done by clinician investigators in academic settings.”

Another advantage of a fellowship, Dr. Arora says, is that it allows you to explore whether you are truly suited for a research career. All three hospitalists agreed that researchers share many of the same abilities: to focus, accept uncertainty, persevere, work in teams, and handle rejection.

The Right Mentorship

Dr. Fang says working with an experienced mentor is a vital ingredient to launching a research career. One key factor in selecting a fellowship program, according to Dr. Leykum, is the institution’s or group’s track record in developing junior faculty. To gain an understanding of how the partnership would work on a practical level, the candidate should ask specific questions of prospective mentors, such as:

• How well do research interests and methodological expertise match?
• How often would we meet?
• Who would be involved in the mentorship team?
• What would each person contribute?

In hospital medicine, it could be challenging to find a mentor within one’s own division. Dr. Fang points out that there are a variety of other ways to obtain career, academic, and research mentorship: For example, SHM’s Research Committee has a fledgling mentoring program, and the Society of General Internal Medicine offers both one-on-one and longitudinal year-long mentoring. “You can also look to other specialty divisions that are complementary,” she suggests. If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.

Balance Clinical, Research Time

Although securing protected research time concerns trainees as well as academic faculty (see “Protect, Make the Most of Your Time,”), deleting clinical time from the equation is not the answer.

“I find, from being a researcher,” says Dr. Arora, “that sometimes you need a break from research. And clinical work can provide that break. Whatever you do, you need a balance.”

Dr. Leykum says she learned, about five years ago, that 10 weeks of clinical rotation was too little. By choice, she elects to put in more clinical time. Why? “Being in that [clinical] environment helps you hone your questions, especially if they concern how to better deliver care,” she says. “In addition, you interact with specialists and learn about the new research that they are implementing.”

The cross-feed between clinical and research pursuits can be particularly rich, Dr. Fang says. In addition to her other posts at UCSF, she is medical director of the anticoagulation clinic.

“I find a lot of my research ideas flow very naturally out of the situations I see as a hospitalist,” she says. “You often see something that you want to improve and design a project to try and achieve those aims.”

Gretchen Henkel is a freelance writer in southern California.

Protect, Make the Most of Your Time

Transitioning from a research fellowship to your first job, you will be negotiating for protected research time. A typical junior faculty position might involve 70% research time and 30% clinical time, says Dr. Arora, who cautions candidates to clarify how the 30% clinical time will be structured. “In a hospitalist group, 30% clinical time can look quite different and have varying amounts of nights and undesirable shifts.” It is appropriate, she noted, to ask this question, because this may have implications for your research time.

Candidates also need clarity from prospective institutions about funding expectations. Be prepared to secure your own funding as soon as possible. “You need to always look ahead,” says Dr. Arora, who suggests that young investigators view their first job as a “mini-grant” and use their time during that period to develop other funding sources, such as the NIH K, or career development, awards. —GH

References

1. Leykum LK, Parekh VI, Sharpe B, Boonyasai RT, Centor RM. Tried and true: a survey of successfully promoted academic hospitalists. J Hosp Med. 2011;6(7):411-415.
2. McKenna K, Leykum LK, McDaniel RR. The role of improvising in patient care. Health Care Manage Rev. 2013;38(1):1-8.
3. Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642-1648.
4. Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153.
5. Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4): 395-401.
6. Mission JF, Kerlan RK, Tan JH, Fang MC. Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients. J Gen Intern Med. 2010;25(4):321-325.

Are you attracted to research but not sure if it’s your sole calling as a prospective hospitalist? Whether you think you might want to steer quality improvement (QI) studies in the community setting or veer toward an academic/research career, hospital medicine offers an array of paths to career satisfaction.

“There is so much room in hospital medicine to find your research niche,” says Luci K. Leykum, MD, MBA, MSc, SFHM, hospital medicine division chief and associate dean for clinical affairs at University of Texas Health Science Center in San Antonio. As chair of SHM’s Research Committee, Dr. Leykum can attest to the range of hospitalists’ research pursuits: from basic science (what biomarkers best predict poor outcomes in patients with acute lung injury?) to care organization (are hospitalist schedules and workload associated with patient outcomes?) to implementation (how do we most effectively implement best practices for care transitions?) studies.^1-6

Dr. Leykum

In addition to Dr. Leykum, The Hospitalist consulted Vineet Arora, MD, MPP, FACP, SFHM, associate professor of medicine at the University of Chicago and chair of SHM’s Physicians in Training Committee, and Margaret Fang, MD, MPH, FHM, associate professor and clinician-investigator in the department of medicine at University of California San Francisco (UCSF) Medical Center and a member of the SHM Research Committee. Critical to research success, they agree, is acquiring skills in research methodology and project design, finding the right mentor(s) to help guide your career, and committing to and preserving time to focus on your research.

“After residency,” Dr. Arora notes, “you have accumulated the clinical skills to become a hospitalist, but you usually have not accumulated the skill it takes to be a researcher, which is why you need to do additional training.”

Is a Fellowship Necessary?

The paths to incorporating research into one’s HM career can be diverse. Although a fellowship is often the recommended route, there are other ways to acquire research methodology and experience with project design. Dr. Leykum began her career as a clinician-educator at Columbia University in New York. Although she found the QI work enjoyable, she realized she wanted to understand how to create more meaningful and sustainable changes in inpatient care delivery. She later acquired a master’s degree in clinical investigation. She has published more than 25 journal articles, several in collaboration with other SHM colleagues.

As a result, perhaps, of her own experience—and the fact that HM is still a young subspecialty with limited HM-specific fellowship opportunities—Dr. Leykum says that she would consider hiring a junior faculty member who had not yet completed a fellowship. “I think you have to consider people who might be talented candidates that you are willing to groom,” she says. However, she says she would structure the position so that the faculty member could immediately pursue additional research training.

“If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.”

–Dr. Fang

Dr. Fang completed a two-year, general medical research fellowship right after her residency and obtained her master of public health degree at that time. “I do agree,” she says, “that the fastest way to doing research well is to get some additional training.”

Even if you are not aiming to become a full-time investigator, Dr. Arora says a research fellowship “gives you very marketable skills. You will still gain skills that will be helpful to your career—and not all research is done by clinician investigators in academic settings.”

Another advantage of a fellowship, Dr. Arora says, is that it allows you to explore whether you are truly suited for a research career. All three hospitalists agreed that researchers share many of the same abilities: to focus, accept uncertainty, persevere, work in teams, and handle rejection.

The Right Mentorship

Dr. Fang says working with an experienced mentor is a vital ingredient to launching a research career. One key factor in selecting a fellowship program, according to Dr. Leykum, is the institution’s or group’s track record in developing junior faculty. To gain an understanding of how the partnership would work on a practical level, the candidate should ask specific questions of prospective mentors, such as:

• How well do research interests and methodological expertise match?
• How often would we meet?
• Who would be involved in the mentorship team?
• What would each person contribute?

In hospital medicine, it could be challenging to find a mentor within one’s own division. Dr. Fang points out that there are a variety of other ways to obtain career, academic, and research mentorship: For example, SHM’s Research Committee has a fledgling mentoring program, and the Society of General Internal Medicine offers both one-on-one and longitudinal year-long mentoring. “You can also look to other specialty divisions that are complementary,” she suggests. If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.

Balance Clinical, Research Time

Although securing protected research time concerns trainees as well as academic faculty (see “Protect, Make the Most of Your Time,”), deleting clinical time from the equation is not the answer.

“I find, from being a researcher,” says Dr. Arora, “that sometimes you need a break from research. And clinical work can provide that break. Whatever you do, you need a balance.”

Dr. Leykum says she learned, about five years ago, that 10 weeks of clinical rotation was too little. By choice, she elects to put in more clinical time. Why? “Being in that [clinical] environment helps you hone your questions, especially if they concern how to better deliver care,” she says. “In addition, you interact with specialists and learn about the new research that they are implementing.”

The cross-feed between clinical and research pursuits can be particularly rich, Dr. Fang says. In addition to her other posts at UCSF, she is medical director of the anticoagulation clinic.

“I find a lot of my research ideas flow very naturally out of the situations I see as a hospitalist,” she says. “You often see something that you want to improve and design a project to try and achieve those aims.”

Gretchen Henkel is a freelance writer in southern California.

Protect, Make the Most of Your Time

Transitioning from a research fellowship to your first job, you will be negotiating for protected research time. A typical junior faculty position might involve 70% research time and 30% clinical time, says Dr. Arora, who cautions candidates to clarify how the 30% clinical time will be structured. “In a hospitalist group, 30% clinical time can look quite different and have varying amounts of nights and undesirable shifts.” It is appropriate, she noted, to ask this question, because this may have implications for your research time.

Candidates also need clarity from prospective institutions about funding expectations. Be prepared to secure your own funding as soon as possible. “You need to always look ahead,” says Dr. Arora, who suggests that young investigators view their first job as a “mini-grant” and use their time during that period to develop other funding sources, such as the NIH K, or career development, awards. —GH

References

1. Leykum LK, Parekh VI, Sharpe B, Boonyasai RT, Centor RM. Tried and true: a survey of successfully promoted academic hospitalists. J Hosp Med. 2011;6(7):411-415.
2. McKenna K, Leykum LK, McDaniel RR. The role of improvising in patient care. Health Care Manage Rev. 2013;38(1):1-8.
3. Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642-1648.
4. Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153.
5. Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4): 395-401.
6. Mission JF, Kerlan RK, Tan JH, Fang MC. Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients. J Gen Intern Med. 2010;25(4):321-325.

Are you attracted to research but not sure if it’s your sole calling as a prospective hospitalist? Whether you think you might want to steer quality improvement (QI) studies in the community setting or veer toward an academic/research career, hospital medicine offers an array of paths to career satisfaction.

“There is so much room in hospital medicine to find your research niche,” says Luci K. Leykum, MD, MBA, MSc, SFHM, hospital medicine division chief and associate dean for clinical affairs at University of Texas Health Science Center in San Antonio. As chair of SHM’s Research Committee, Dr. Leykum can attest to the range of hospitalists’ research pursuits: from basic science (what biomarkers best predict poor outcomes in patients with acute lung injury?) to care organization (are hospitalist schedules and workload associated with patient outcomes?) to implementation (how do we most effectively implement best practices for care transitions?) studies.^1-6

Dr. Leykum

In addition to Dr. Leykum, The Hospitalist consulted Vineet Arora, MD, MPP, FACP, SFHM, associate professor of medicine at the University of Chicago and chair of SHM’s Physicians in Training Committee, and Margaret Fang, MD, MPH, FHM, associate professor and clinician-investigator in the department of medicine at University of California San Francisco (UCSF) Medical Center and a member of the SHM Research Committee. Critical to research success, they agree, is acquiring skills in research methodology and project design, finding the right mentor(s) to help guide your career, and committing to and preserving time to focus on your research.

“After residency,” Dr. Arora notes, “you have accumulated the clinical skills to become a hospitalist, but you usually have not accumulated the skill it takes to be a researcher, which is why you need to do additional training.”

Is a Fellowship Necessary?

The paths to incorporating research into one’s HM career can be diverse. Although a fellowship is often the recommended route, there are other ways to acquire research methodology and experience with project design. Dr. Leykum began her career as a clinician-educator at Columbia University in New York. Although she found the QI work enjoyable, she realized she wanted to understand how to create more meaningful and sustainable changes in inpatient care delivery. She later acquired a master’s degree in clinical investigation. She has published more than 25 journal articles, several in collaboration with other SHM colleagues.

As a result, perhaps, of her own experience—and the fact that HM is still a young subspecialty with limited HM-specific fellowship opportunities—Dr. Leykum says that she would consider hiring a junior faculty member who had not yet completed a fellowship. “I think you have to consider people who might be talented candidates that you are willing to groom,” she says. However, she says she would structure the position so that the faculty member could immediately pursue additional research training.

“If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.”

–Dr. Fang

Dr. Fang completed a two-year, general medical research fellowship right after her residency and obtained her master of public health degree at that time. “I do agree,” she says, “that the fastest way to doing research well is to get some additional training.”

Even if you are not aiming to become a full-time investigator, Dr. Arora says a research fellowship “gives you very marketable skills. You will still gain skills that will be helpful to your career—and not all research is done by clinician investigators in academic settings.”

Another advantage of a fellowship, Dr. Arora says, is that it allows you to explore whether you are truly suited for a research career. All three hospitalists agreed that researchers share many of the same abilities: to focus, accept uncertainty, persevere, work in teams, and handle rejection.

The Right Mentorship

Dr. Fang says working with an experienced mentor is a vital ingredient to launching a research career. One key factor in selecting a fellowship program, according to Dr. Leykum, is the institution’s or group’s track record in developing junior faculty. To gain an understanding of how the partnership would work on a practical level, the candidate should ask specific questions of prospective mentors, such as:

• How well do research interests and methodological expertise match?
• How often would we meet?
• Who would be involved in the mentorship team?
• What would each person contribute?

In hospital medicine, it could be challenging to find a mentor within one’s own division. Dr. Fang points out that there are a variety of other ways to obtain career, academic, and research mentorship: For example, SHM’s Research Committee has a fledgling mentoring program, and the Society of General Internal Medicine offers both one-on-one and longitudinal year-long mentoring. “You can also look to other specialty divisions that are complementary,” she suggests. If you’re interested in antimicrobial stewardship, for example, your institution’s division of infectious disease might be a logical choice for your mentorship and collaboration search.

Balance Clinical, Research Time

Although securing protected research time concerns trainees as well as academic faculty (see “Protect, Make the Most of Your Time,”), deleting clinical time from the equation is not the answer.

“I find, from being a researcher,” says Dr. Arora, “that sometimes you need a break from research. And clinical work can provide that break. Whatever you do, you need a balance.”

Dr. Leykum says she learned, about five years ago, that 10 weeks of clinical rotation was too little. By choice, she elects to put in more clinical time. Why? “Being in that [clinical] environment helps you hone your questions, especially if they concern how to better deliver care,” she says. “In addition, you interact with specialists and learn about the new research that they are implementing.”

The cross-feed between clinical and research pursuits can be particularly rich, Dr. Fang says. In addition to her other posts at UCSF, she is medical director of the anticoagulation clinic.

“I find a lot of my research ideas flow very naturally out of the situations I see as a hospitalist,” she says. “You often see something that you want to improve and design a project to try and achieve those aims.”

Gretchen Henkel is a freelance writer in southern California.

Protect, Make the Most of Your Time

Transitioning from a research fellowship to your first job, you will be negotiating for protected research time. A typical junior faculty position might involve 70% research time and 30% clinical time, says Dr. Arora, who cautions candidates to clarify how the 30% clinical time will be structured. “In a hospitalist group, 30% clinical time can look quite different and have varying amounts of nights and undesirable shifts.” It is appropriate, she noted, to ask this question, because this may have implications for your research time.

Candidates also need clarity from prospective institutions about funding expectations. Be prepared to secure your own funding as soon as possible. “You need to always look ahead,” says Dr. Arora, who suggests that young investigators view their first job as a “mini-grant” and use their time during that period to develop other funding sources, such as the NIH K, or career development, awards. —GH

References

1. Leykum LK, Parekh VI, Sharpe B, Boonyasai RT, Centor RM. Tried and true: a survey of successfully promoted academic hospitalists. J Hosp Med. 2011;6(7):411-415.
2. McKenna K, Leykum LK, McDaniel RR. The role of improvising in patient care. Health Care Manage Rev. 2013;38(1):1-8.
3. Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642-1648.
4. Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153.
5. Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4): 395-401.
6. Mission JF, Kerlan RK, Tan JH, Fang MC. Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients. J Gen Intern Med. 2010;25(4):321-325.

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When she isn’t attending to patients or grappling with the latest update to electronic health records (EHR), Midori Larrabee, MD, is getting her hands dirty.

Literally.

Dr. Larrabee, a former hospitalist medical director at the 30-bed Valley General Hospital in Monroe, Wash., and her husband live on 2.5 acres of “paradise” outside of Seattle. They grow their own vegetables and recently planted an orchard. “We hope to get chickens next year,” she says.

“I love cooking and spending time with my husband, enjoying our little paradise,” says Dr. Larrabee, now working full-time as a hospitalist at 349-bed Overlake Medical Center in Bellevue, Wash. “I think being a hospitalist will only be sustainable if I have time away from the hospital to think about non-medical issues—like what worm is eating my radishes.”

Leisure-time passions aside, Dr. Larrabee chose HM for many of the same reasons hospitalists around the country do: “a variety of patients, the acuity of care, and the flexibility of the schedule. With half of the month off, I have time for activities other than clinical medicine.”

She considers herself a problem solver, using both sides of the brain to care for patients, mitigate staff schedules, and contribute to quality improvement projects.

“Initially, I was attracted to medicine due to my interest in biochemistry and the physiology of how we function,” says Dr. Larrabee, one of nine new members of Team Hospitalist, the volunteer, editorial advisory group for The Hospitalist. “As I’ve grown up, I started to see the value in being a part of patients/families’ lives during an event like a hospitalization. I can use my knowledge to help guide them, educate them, and, hopefully, reassure them during a time when they may feel helpless.”

Question: How did you decide to become a hospitalist?

Answer: I decided to become a hospitalist during residency. Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases. Also, I liked dealing with sicker patients where more acute decisions had to be made and the results were quickly evident.

Q: Outside of patient care, tell me about your career interests?

A: I am on the P&T committee at (Overlake), and work as part of a team developing projects to improve patient satisfaction during their hospitalization. During the summers I perform evaluations of local medic students at the end of their training program (done through the Seattle Fire Department). I have previously been on the Medical Executive Committee at my smaller hospital and really enjoyed those activities. I would like to be more involved in quality projects at my hospital and hopefully will find some opportunities in the next year.

Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases.

–Dr. Larrabee

Q: What’s the best advice you ever received?

A: Make yourself happy. If you keep coming back to the question “Am I happy?” you can always have a way to center yourself. If you say “Yes,” then you can feel good about where you are in life, even if that wasn’t what you were expecting or planning. If you say “No,” then at least you now know that something needs to change.

Q: What’s the one thing you most dislike about your job?

A: The time spent with the electronic health record. I am spending more time figuring out how to order a therapy, write a note, or sign an order than actually at the bedside interacting with the patient.

Q: What is your biggest professional challenge?

A: My lack of patience. I want to be in more leadership positions, be a respected physician at my hospital, and have a greater role in the community NOW. I have only worked at my larger hospital for about a year, and I know it takes time to get to know everyone, get to know the culture of the hospital, and work my way up the ranks.

Q: What is your biggest professional reward?

A: I love when I really connect with a patient or family and feel like I’ve made a difference. As a hospitalist, it sometimes feels like I am admitting patients with chronic medical problems that will never get better, get them just well enough to leave the hospital, but never really make a difference. When you can really connect, that is always a great reward. An example is an elderly patient I cared for recently. He was clearly dying, but the family was having a hard time accepting his course. I spent time with the family and helped them reconcile their hopes to keep him comfortable with their fears about killing the patriarch of the family. They eventually transitioned the patient to hospice care, and although he did pass away, I feel like I was able to make the patient’s death a little better for the family and for him.

Q: Where do you see yourself in 10 years?

A: I always see myself working clinically for at least part of my time. Medicine would get too boring if it wasn’t for the patients. That said, I like a variety of activities and stay motivated when something new is on the horizon. I don’t know if a climb up the ladder is in my future, but if things work out that way, I would be open to the chance. Otherwise, I try and keep my eyes out for new challenges. If I try and plan my path out too much, I will miss those great, unexpected opportunities.

Q: What’s the best book you’ve read recently?

A: “Vegetable Literacy” by Deborah Madison. I love to cook and garden, and this book describes the different edible members of botanical families—and then gives recipes. The book motivates you to try new varieties in the garden and kitchen. The beautiful pictures didn’t hurt, either. Pictures always make a book better.

Q: How many Apple products do you interface with in a given week?

A: One, my iPhone. AppleTV never works right, so we stopped trying to use that months ago.

Richard Quinn is a freelance writer in New Jersey.

When she isn’t attending to patients or grappling with the latest update to electronic health records (EHR), Midori Larrabee, MD, is getting her hands dirty.

Literally.

Dr. Larrabee, a former hospitalist medical director at the 30-bed Valley General Hospital in Monroe, Wash., and her husband live on 2.5 acres of “paradise” outside of Seattle. They grow their own vegetables and recently planted an orchard. “We hope to get chickens next year,” she says.

“I love cooking and spending time with my husband, enjoying our little paradise,” says Dr. Larrabee, now working full-time as a hospitalist at 349-bed Overlake Medical Center in Bellevue, Wash. “I think being a hospitalist will only be sustainable if I have time away from the hospital to think about non-medical issues—like what worm is eating my radishes.”

Leisure-time passions aside, Dr. Larrabee chose HM for many of the same reasons hospitalists around the country do: “a variety of patients, the acuity of care, and the flexibility of the schedule. With half of the month off, I have time for activities other than clinical medicine.”

She considers herself a problem solver, using both sides of the brain to care for patients, mitigate staff schedules, and contribute to quality improvement projects.

“Initially, I was attracted to medicine due to my interest in biochemistry and the physiology of how we function,” says Dr. Larrabee, one of nine new members of Team Hospitalist, the volunteer, editorial advisory group for The Hospitalist. “As I’ve grown up, I started to see the value in being a part of patients/families’ lives during an event like a hospitalization. I can use my knowledge to help guide them, educate them, and, hopefully, reassure them during a time when they may feel helpless.”

Question: How did you decide to become a hospitalist?

Answer: I decided to become a hospitalist during residency. Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases. Also, I liked dealing with sicker patients where more acute decisions had to be made and the results were quickly evident.

Q: Outside of patient care, tell me about your career interests?

A: I am on the P&T committee at (Overlake), and work as part of a team developing projects to improve patient satisfaction during their hospitalization. During the summers I perform evaluations of local medic students at the end of their training program (done through the Seattle Fire Department). I have previously been on the Medical Executive Committee at my smaller hospital and really enjoyed those activities. I would like to be more involved in quality projects at my hospital and hopefully will find some opportunities in the next year.

Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases.

–Dr. Larrabee

Q: What’s the best advice you ever received?

A: Make yourself happy. If you keep coming back to the question “Am I happy?” you can always have a way to center yourself. If you say “Yes,” then you can feel good about where you are in life, even if that wasn’t what you were expecting or planning. If you say “No,” then at least you now know that something needs to change.

Q: What’s the one thing you most dislike about your job?

A: The time spent with the electronic health record. I am spending more time figuring out how to order a therapy, write a note, or sign an order than actually at the bedside interacting with the patient.

Q: What is your biggest professional challenge?

A: My lack of patience. I want to be in more leadership positions, be a respected physician at my hospital, and have a greater role in the community NOW. I have only worked at my larger hospital for about a year, and I know it takes time to get to know everyone, get to know the culture of the hospital, and work my way up the ranks.

Q: What is your biggest professional reward?

A: I love when I really connect with a patient or family and feel like I’ve made a difference. As a hospitalist, it sometimes feels like I am admitting patients with chronic medical problems that will never get better, get them just well enough to leave the hospital, but never really make a difference. When you can really connect, that is always a great reward. An example is an elderly patient I cared for recently. He was clearly dying, but the family was having a hard time accepting his course. I spent time with the family and helped them reconcile their hopes to keep him comfortable with their fears about killing the patriarch of the family. They eventually transitioned the patient to hospice care, and although he did pass away, I feel like I was able to make the patient’s death a little better for the family and for him.

Q: Where do you see yourself in 10 years?

A: I always see myself working clinically for at least part of my time. Medicine would get too boring if it wasn’t for the patients. That said, I like a variety of activities and stay motivated when something new is on the horizon. I don’t know if a climb up the ladder is in my future, but if things work out that way, I would be open to the chance. Otherwise, I try and keep my eyes out for new challenges. If I try and plan my path out too much, I will miss those great, unexpected opportunities.

Q: What’s the best book you’ve read recently?

A: “Vegetable Literacy” by Deborah Madison. I love to cook and garden, and this book describes the different edible members of botanical families—and then gives recipes. The book motivates you to try new varieties in the garden and kitchen. The beautiful pictures didn’t hurt, either. Pictures always make a book better.

Q: How many Apple products do you interface with in a given week?

A: One, my iPhone. AppleTV never works right, so we stopped trying to use that months ago.

Richard Quinn is a freelance writer in New Jersey.

When she isn’t attending to patients or grappling with the latest update to electronic health records (EHR), Midori Larrabee, MD, is getting her hands dirty.

Literally.

Dr. Larrabee, a former hospitalist medical director at the 30-bed Valley General Hospital in Monroe, Wash., and her husband live on 2.5 acres of “paradise” outside of Seattle. They grow their own vegetables and recently planted an orchard. “We hope to get chickens next year,” she says.

“I love cooking and spending time with my husband, enjoying our little paradise,” says Dr. Larrabee, now working full-time as a hospitalist at 349-bed Overlake Medical Center in Bellevue, Wash. “I think being a hospitalist will only be sustainable if I have time away from the hospital to think about non-medical issues—like what worm is eating my radishes.”

Leisure-time passions aside, Dr. Larrabee chose HM for many of the same reasons hospitalists around the country do: “a variety of patients, the acuity of care, and the flexibility of the schedule. With half of the month off, I have time for activities other than clinical medicine.”

She considers herself a problem solver, using both sides of the brain to care for patients, mitigate staff schedules, and contribute to quality improvement projects.

“Initially, I was attracted to medicine due to my interest in biochemistry and the physiology of how we function,” says Dr. Larrabee, one of nine new members of Team Hospitalist, the volunteer, editorial advisory group for The Hospitalist. “As I’ve grown up, I started to see the value in being a part of patients/families’ lives during an event like a hospitalization. I can use my knowledge to help guide them, educate them, and, hopefully, reassure them during a time when they may feel helpless.”

Question: How did you decide to become a hospitalist?

Answer: I decided to become a hospitalist during residency. Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases. Also, I liked dealing with sicker patients where more acute decisions had to be made and the results were quickly evident.

Q: Outside of patient care, tell me about your career interests?

A: I am on the P&T committee at (Overlake), and work as part of a team developing projects to improve patient satisfaction during their hospitalization. During the summers I perform evaluations of local medic students at the end of their training program (done through the Seattle Fire Department). I have previously been on the Medical Executive Committee at my smaller hospital and really enjoyed those activities. I would like to be more involved in quality projects at my hospital and hopefully will find some opportunities in the next year.

Even though the ward months were grueling, I loved being part of an inpatient team and managing the variety of patients that came through the door. I liked all of my subspecialty rotations but didn’t want to lose the ability to manage multiple diseases.

–Dr. Larrabee

Q: What’s the best advice you ever received?

A: Make yourself happy. If you keep coming back to the question “Am I happy?” you can always have a way to center yourself. If you say “Yes,” then you can feel good about where you are in life, even if that wasn’t what you were expecting or planning. If you say “No,” then at least you now know that something needs to change.

Q: What’s the one thing you most dislike about your job?

A: The time spent with the electronic health record. I am spending more time figuring out how to order a therapy, write a note, or sign an order than actually at the bedside interacting with the patient.

Q: What is your biggest professional challenge?

A: My lack of patience. I want to be in more leadership positions, be a respected physician at my hospital, and have a greater role in the community NOW. I have only worked at my larger hospital for about a year, and I know it takes time to get to know everyone, get to know the culture of the hospital, and work my way up the ranks.

Q: What is your biggest professional reward?

A: I love when I really connect with a patient or family and feel like I’ve made a difference. As a hospitalist, it sometimes feels like I am admitting patients with chronic medical problems that will never get better, get them just well enough to leave the hospital, but never really make a difference. When you can really connect, that is always a great reward. An example is an elderly patient I cared for recently. He was clearly dying, but the family was having a hard time accepting his course. I spent time with the family and helped them reconcile their hopes to keep him comfortable with their fears about killing the patriarch of the family. They eventually transitioned the patient to hospice care, and although he did pass away, I feel like I was able to make the patient’s death a little better for the family and for him.

Q: Where do you see yourself in 10 years?

A: I always see myself working clinically for at least part of my time. Medicine would get too boring if it wasn’t for the patients. That said, I like a variety of activities and stay motivated when something new is on the horizon. I don’t know if a climb up the ladder is in my future, but if things work out that way, I would be open to the chance. Otherwise, I try and keep my eyes out for new challenges. If I try and plan my path out too much, I will miss those great, unexpected opportunities.

Q: What’s the best book you’ve read recently?

A: “Vegetable Literacy” by Deborah Madison. I love to cook and garden, and this book describes the different edible members of botanical families—and then gives recipes. The book motivates you to try new varieties in the garden and kitchen. The beautiful pictures didn’t hurt, either. Pictures always make a book better.

Q: How many Apple products do you interface with in a given week?

A: One, my iPhone. AppleTV never works right, so we stopped trying to use that months ago.

Richard Quinn is a freelance writer in New Jersey.

Under the leadership of David Meltzer, MD, PhD, MHM, the University of Chicago Hospitalist Scholars Program is one of 13 organizations to earn the prestigious Association of American Medical Colleges’ Learning Health System Challenge and Planning Awards.

The program provides training in research, medical education, and quality improvement to help young physicians develop into successful academic hospitalists who can become leaders in these domains. Required resources include mentorship and opportunities for formal didactic instruction for the scholars and a functioning clinical research environment.

The AAMC Learning Health System Challenge and Planning Awards recognize innovations in medical education, care delivery, research, and diversity and inclusion.

Under the leadership of David Meltzer, MD, PhD, MHM, the University of Chicago Hospitalist Scholars Program is one of 13 organizations to earn the prestigious Association of American Medical Colleges’ Learning Health System Challenge and Planning Awards.

The program provides training in research, medical education, and quality improvement to help young physicians develop into successful academic hospitalists who can become leaders in these domains. Required resources include mentorship and opportunities for formal didactic instruction for the scholars and a functioning clinical research environment.

The AAMC Learning Health System Challenge and Planning Awards recognize innovations in medical education, care delivery, research, and diversity and inclusion.

Under the leadership of David Meltzer, MD, PhD, MHM, the University of Chicago Hospitalist Scholars Program is one of 13 organizations to earn the prestigious Association of American Medical Colleges’ Learning Health System Challenge and Planning Awards.

The program provides training in research, medical education, and quality improvement to help young physicians develop into successful academic hospitalists who can become leaders in these domains. Required resources include mentorship and opportunities for formal didactic instruction for the scholars and a functioning clinical research environment.

The AAMC Learning Health System Challenge and Planning Awards recognize innovations in medical education, care delivery, research, and diversity and inclusion.

“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.

For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.

The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.

At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.

SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.

At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.

Joshua Lapps is SHM’s government relations specialist.

“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.

For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.

The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.

At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.

SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.

At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.

Joshua Lapps is SHM’s government relations specialist.

“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.

For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.

The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.

At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.

SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.

At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.

Joshua Lapps is SHM’s government relations specialist.