Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best.

–Jeffrey Schnipper, MD, MPH, FHM

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.

Larry Beresford is a freelance writer in San Francisco.

Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best.

–Jeffrey Schnipper, MD, MPH, FHM

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.

Larry Beresford is a freelance writer in San Francisco.

Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best.

–Jeffrey Schnipper, MD, MPH, FHM

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.

Larry Beresford is a freelance writer in San Francisco.

click for large version

Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.¹ Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.² To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.

Defining Critical Illness/Injury

CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).³ The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.⁴

Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:

• Patients admitted to a critical-care unit because no other hospital beds were available;
• Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
• Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
• Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).

These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.^3,5

Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).⁴ Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).

Code This Case

Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.

Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.^5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.

Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.

Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.⁶

Critically ill patients often require the care of multiple providers.³ Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.⁸ Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.

Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).

When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.

More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.

Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.

Critical-Care Services: Time Reminders

click for large version

Two available codes:

99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.

+99292: Critical care, evaluation and management of the critically ill or critically injured patient: each additional 30 minutes (list separately in addition to code for primary service). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).

Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilation management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).⁵

Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.

Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.

—Carol Pohlig

References

1. Cahaba Government Benefit Administrators LLC. Widespread prepayment targeted review notification—CPT 99291. Cahaba Government Benefit Administrators LLC website. Available at: http://www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed May 4, 2013.
2. First Coast Service Options Inc. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options Inc. website. Available at: http://medicare.fcso.com/Medical_documentation/249650.asp. Accessed May 5, 2013.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12B. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12E. Centers for Medicare and Medicaid Services website. Available at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2013.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. Current Procedural Terminology 2013 Professional Edition. Chicago: American Medical Association Press; 2012.
7. Novitas Solutions Inc. Evaluation & management: service-specific coding instructions. Novitas Solutions Inc. website. Available at: http://www.novitas-solutions.com/em/coding.html. Accessed May 7, 2013.
8. United Healthcare. Same day same service policy—adding edits. United Healthcare website. Available at: http://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/ UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November _2012_Volume_52.pdf. Accessed May 7, 2013.
9. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12I. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 10, 2013.
10. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12G. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 4, 2013.

click for large version

Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.¹ Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.² To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.

Defining Critical Illness/Injury

CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).³ The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.⁴

Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:

• Patients admitted to a critical-care unit because no other hospital beds were available;
• Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
• Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
• Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).

These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.^3,5

Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).⁴ Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).

Code This Case

Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.

Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.^5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.

Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.

Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.⁶

Critically ill patients often require the care of multiple providers.³ Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.⁸ Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.

Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).

When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.

More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.

Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.

Critical-Care Services: Time Reminders

click for large version

Two available codes:

99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.

+99292: Critical care, evaluation and management of the critically ill or critically injured patient: each additional 30 minutes (list separately in addition to code for primary service). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).

Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilation management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).⁵

Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.

Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.

—Carol Pohlig

References

1. Cahaba Government Benefit Administrators LLC. Widespread prepayment targeted review notification—CPT 99291. Cahaba Government Benefit Administrators LLC website. Available at: http://www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed May 4, 2013.
2. First Coast Service Options Inc. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options Inc. website. Available at: http://medicare.fcso.com/Medical_documentation/249650.asp. Accessed May 5, 2013.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12B. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12E. Centers for Medicare and Medicaid Services website. Available at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2013.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. Current Procedural Terminology 2013 Professional Edition. Chicago: American Medical Association Press; 2012.
7. Novitas Solutions Inc. Evaluation & management: service-specific coding instructions. Novitas Solutions Inc. website. Available at: http://www.novitas-solutions.com/em/coding.html. Accessed May 7, 2013.
8. United Healthcare. Same day same service policy—adding edits. United Healthcare website. Available at: http://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/ UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November _2012_Volume_52.pdf. Accessed May 7, 2013.
9. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12I. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 10, 2013.
10. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12G. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 4, 2013.

click for large version

Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.¹ Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.² To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.

Defining Critical Illness/Injury

CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).³ The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.⁴

Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:

• Patients admitted to a critical-care unit because no other hospital beds were available;
• Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
• Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
• Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).

These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.^3,5

Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).⁴ Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).

Code This Case

Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.

Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.^5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.

Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.

Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.⁶

Critically ill patients often require the care of multiple providers.³ Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.⁸ Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.

Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).

When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.

More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.

Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.

Critical-Care Services: Time Reminders

click for large version

Two available codes:

99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.

+99292: Critical care, evaluation and management of the critically ill or critically injured patient: each additional 30 minutes (list separately in addition to code for primary service). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).

Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilation management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).⁵

Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.

Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.

—Carol Pohlig

References

1. Cahaba Government Benefit Administrators LLC. Widespread prepayment targeted review notification—CPT 99291. Cahaba Government Benefit Administrators LLC website. Available at: http://www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed May 4, 2013.
2. First Coast Service Options Inc. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options Inc. website. Available at: http://medicare.fcso.com/Medical_documentation/249650.asp. Accessed May 5, 2013.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12B. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12E. Centers for Medicare and Medicaid Services website. Available at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2013.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. Current Procedural Terminology 2013 Professional Edition. Chicago: American Medical Association Press; 2012.
7. Novitas Solutions Inc. Evaluation & management: service-specific coding instructions. Novitas Solutions Inc. website. Available at: http://www.novitas-solutions.com/em/coding.html. Accessed May 7, 2013.
8. United Healthcare. Same day same service policy—adding edits. United Healthcare website. Available at: http://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/ UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November _2012_Volume_52.pdf. Accessed May 7, 2013.
9. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12I. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 10, 2013.
10. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12G. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 4, 2013.

Key Takeaways for Hospitalist Groups

• Covered entities and business associates should review their business associate agreements and determine whether the agreements qualify for grandfathered status and, if needed, enter into new business-associate agreements.
• Covered entities and business associates will need to review their policies and procedures so that they can implement all necessary changes in a timely manner.
• Notices of Privacy Practices will need to be revised, and appropriate training should be provided to personnel of covered entities and business associates.
• Any vendor or business that performs functions for a covered entity or another business associate involving the use or disclosure of PHI should determine whether it is a “business associate” and, if so, what needs to be done in order to comply with the Final Rule.

On Jan. 17, 2013, the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) issued an omnibus Final Rule implementing various provisions of the Health Information Technology for Economic and Clinical Health, or HITECH, Act. The Final Rule revises the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the interim final Breach Notification Rule.

The HITECH Act, which took effect as part of the American Recovery and Reinvestment Act of 2009, expanded the obligations of covered entities and business associates to protect the confidentiality and security of protected health information (PHI).

Under HIPAA, “covered entities” may disclose PHI to “business associates,” and permit business associates to create and receive PHI on behalf of the covered entity, subject to the terms of a business-associate agreement between the parties. A “covered entity” is defined as a health plan, healthcare clearinghouse, or healthcare provider (e.g. physician practice or hospital) that transmits health information electronically. In general, the HIPAA regulations have traditionally defined a “business associate” as a person (other than a member of the covered entity’s workforce) or entity who, on behalf of a covered entity, performs a function or activity involving the use or disclosure of PHI, such as the performance of financial, legal, actuarial, accounting, consulting, data aggregation, management, administrative, or accreditation services to or for a covered entity.

Prior to the HITECH Act, business associates were contractually obligated to maintain the privacy and security of PHI but could not be sanctioned for failing to comply with HIPAA. The HITECH Act expands those obligations and exposure of business associates by:

1. Applying many of the privacy and security standards to business associates;
2. Subjecting business associates to the breach-notification requirements; and
3. Imposing civil and criminal penalties on business associates for HIPAA violations.

In addition, the HITECH Act strengthened the penalties and enforcement mechanisms under HIPAA and required periodic audits to ensure that covered entities and business associates are compliant.

Expansion of Breach-Notification Requirements

The Final Rule expands the breach-notification obligations of covered entities and business associates by revising the definition of “breach” and the risk-assessment process for determining whether notification is required. A use or disclosure of unsecured PHI that is not permitted under the Privacy Rule is presumed to be a breach (and therefore requires notification to the individual, OCR, and possibly the media) unless the incident satisfies an exception, or the covered entity or business associate demonstrates a low probability that PHI has been compromised.1 This risk analysis is based on at least the following four factors:

1. The nature and extent of the PHI, including the types of identifiers and the likelihood of re-identification;
2. The unauthorized person who used or accessed the PHI;
3. Whether the PHI was actually acquired or viewed; and
4. The extent to which the risk is mitigated (e.g. by obtaining reliable assurances by a recipient of PHI that the information will be destroyed or will not be used or disclosed).

Expansion of Business-Associate Obligations

The Final Rule implements the HITECH Act’s expansion of business associates’ HIPAA obligations by applying the Privacy and Security Rules directly to business associates and by imposing civil and criminal penalties on business associates for HIPAA violations. It also extends obligations and potential penalties to subcontractors of business associates if a business associate delegates a function, activity, or service to the subcontractor, and the subcontractor creates, receives, maintains, or transmits PHI on behalf of the business associate. Any business associate that delegates a function involving the use or disclosure of PHI to a subcontractor will be required to enter into a business-associate agreement with the subcontractor.

Additional Provisions

The Final Rule addresses the following additional issues by:

• Requiring covered entities to modify their Notices of Privacy Practices;
• Allowing individuals to obtain a copy of PHI in an electronic format if the covered entity uses an electronic health record;
• Restricting marketing activities;
• Allowing covered entities to disclose relevant PHI of a deceased person to a family member, close friend, or other person designated by the deceased, unless the disclosure is inconsistent with the deceased person’s known prior expressed preference;
• Requiring covered entities to agree to an individual’s request to restrict disclosure of PHI to a health plan when the individual (or someone other than the health plan) pays for the healthcare item or service in full;
• Revising the definition of PHI to exclude information about a person who has been deceased for more than 50 years;
• Prohibiting the sale of PHI without authorization from the individual, and adding a requirement of authorization in order for a covered entity to receive remuneration for disclosing PHI;
• Clarifying OCR’s view that covered entities are allowed to send electronic PHI to individuals in unencrypted e-mails only after notifying the individual of the risk;
• Prohibiting health plans from using or disclosing genetic information for underwriting, as required by the Genetic Information Nondiscrimination Act of 2008 (GINA);
• Allowing disclosure of proof of immunization to schools if agreed by the parent, guardian, or individual;
• Permitting compound authorizations for clinical-research studies; and
• Revising the Enforcement Rule (which was previously revised in 2009 as an interim Final Rule), which:

  • Requires the secretary of HHS to investigate a HIPAA complaint if a preliminary investigation indicates a possible violation due to willful neglect;
  • Permits HHS to disclose PHI to other government agencies (including state attorneys general) for civil or criminal law-enforcement purposes; and
  • Revises standards for determining the levels of civil money penalties.

Effective Date, Compliance Date

Although most provisions of the Final Rule became effective on March 26, many provisions impacting covered entities and business associates (including subcontractors) required compliance by Sept. 23. However, if certain conditions are met, the Final Rule allows additional time to revise business associate agreements to make them compliant. In particular, transition provisions will allow covered entities and business associates to continue to operate under existing business-associate agreements for up to one year beyond the compliance date (until Sept. 22, 2014) if the business-associate agreement:

1. Is in writing;
2. Is in place prior to Jan. 25, 2013 (the publication date of the Final Rule);
3. Is compliant with the Privacy and Security Rules, in effect immediately prior to Jan. 25, 2013; and
4. Is not modified or renewed.

This additional time for grandfathered business-associate agreements applies only to the written-documentation requirement. Covered entities, business associates and subcontractors will be required to comply with all other HIPAA requirements beginning on the compliance date, even if the business-associate agreement qualifies for grandfathered status

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Footnote

The exceptions relate to (i) unintentional, good-faith access, acquisition or use by members of the covered entity’s or business associate’s workforce, (ii) inadvertent disclosure limited to persons with authorized access and not resulting in further unpermitted use or disclosure, and (iii) good-faith belief that the unauthorized recipient would be unable to retain the PHI.

Key Takeaways for Hospitalist Groups

• Covered entities and business associates should review their business associate agreements and determine whether the agreements qualify for grandfathered status and, if needed, enter into new business-associate agreements.
• Covered entities and business associates will need to review their policies and procedures so that they can implement all necessary changes in a timely manner.
• Notices of Privacy Practices will need to be revised, and appropriate training should be provided to personnel of covered entities and business associates.
• Any vendor or business that performs functions for a covered entity or another business associate involving the use or disclosure of PHI should determine whether it is a “business associate” and, if so, what needs to be done in order to comply with the Final Rule.

On Jan. 17, 2013, the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) issued an omnibus Final Rule implementing various provisions of the Health Information Technology for Economic and Clinical Health, or HITECH, Act. The Final Rule revises the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the interim final Breach Notification Rule.

The HITECH Act, which took effect as part of the American Recovery and Reinvestment Act of 2009, expanded the obligations of covered entities and business associates to protect the confidentiality and security of protected health information (PHI).

Under HIPAA, “covered entities” may disclose PHI to “business associates,” and permit business associates to create and receive PHI on behalf of the covered entity, subject to the terms of a business-associate agreement between the parties. A “covered entity” is defined as a health plan, healthcare clearinghouse, or healthcare provider (e.g. physician practice or hospital) that transmits health information electronically. In general, the HIPAA regulations have traditionally defined a “business associate” as a person (other than a member of the covered entity’s workforce) or entity who, on behalf of a covered entity, performs a function or activity involving the use or disclosure of PHI, such as the performance of financial, legal, actuarial, accounting, consulting, data aggregation, management, administrative, or accreditation services to or for a covered entity.

Prior to the HITECH Act, business associates were contractually obligated to maintain the privacy and security of PHI but could not be sanctioned for failing to comply with HIPAA. The HITECH Act expands those obligations and exposure of business associates by:

1. Applying many of the privacy and security standards to business associates;
2. Subjecting business associates to the breach-notification requirements; and
3. Imposing civil and criminal penalties on business associates for HIPAA violations.

In addition, the HITECH Act strengthened the penalties and enforcement mechanisms under HIPAA and required periodic audits to ensure that covered entities and business associates are compliant.

Expansion of Breach-Notification Requirements

The Final Rule expands the breach-notification obligations of covered entities and business associates by revising the definition of “breach” and the risk-assessment process for determining whether notification is required. A use or disclosure of unsecured PHI that is not permitted under the Privacy Rule is presumed to be a breach (and therefore requires notification to the individual, OCR, and possibly the media) unless the incident satisfies an exception, or the covered entity or business associate demonstrates a low probability that PHI has been compromised.1 This risk analysis is based on at least the following four factors:

1. The nature and extent of the PHI, including the types of identifiers and the likelihood of re-identification;
2. The unauthorized person who used or accessed the PHI;
3. Whether the PHI was actually acquired or viewed; and
4. The extent to which the risk is mitigated (e.g. by obtaining reliable assurances by a recipient of PHI that the information will be destroyed or will not be used or disclosed).

Expansion of Business-Associate Obligations

The Final Rule implements the HITECH Act’s expansion of business associates’ HIPAA obligations by applying the Privacy and Security Rules directly to business associates and by imposing civil and criminal penalties on business associates for HIPAA violations. It also extends obligations and potential penalties to subcontractors of business associates if a business associate delegates a function, activity, or service to the subcontractor, and the subcontractor creates, receives, maintains, or transmits PHI on behalf of the business associate. Any business associate that delegates a function involving the use or disclosure of PHI to a subcontractor will be required to enter into a business-associate agreement with the subcontractor.

Additional Provisions

The Final Rule addresses the following additional issues by:

• Requiring covered entities to modify their Notices of Privacy Practices;
• Allowing individuals to obtain a copy of PHI in an electronic format if the covered entity uses an electronic health record;
• Restricting marketing activities;
• Allowing covered entities to disclose relevant PHI of a deceased person to a family member, close friend, or other person designated by the deceased, unless the disclosure is inconsistent with the deceased person’s known prior expressed preference;
• Requiring covered entities to agree to an individual’s request to restrict disclosure of PHI to a health plan when the individual (or someone other than the health plan) pays for the healthcare item or service in full;
• Revising the definition of PHI to exclude information about a person who has been deceased for more than 50 years;
• Prohibiting the sale of PHI without authorization from the individual, and adding a requirement of authorization in order for a covered entity to receive remuneration for disclosing PHI;
• Clarifying OCR’s view that covered entities are allowed to send electronic PHI to individuals in unencrypted e-mails only after notifying the individual of the risk;
• Prohibiting health plans from using or disclosing genetic information for underwriting, as required by the Genetic Information Nondiscrimination Act of 2008 (GINA);
• Allowing disclosure of proof of immunization to schools if agreed by the parent, guardian, or individual;
• Permitting compound authorizations for clinical-research studies; and
• Revising the Enforcement Rule (which was previously revised in 2009 as an interim Final Rule), which:

  • Requires the secretary of HHS to investigate a HIPAA complaint if a preliminary investigation indicates a possible violation due to willful neglect;
  • Permits HHS to disclose PHI to other government agencies (including state attorneys general) for civil or criminal law-enforcement purposes; and
  • Revises standards for determining the levels of civil money penalties.

Effective Date, Compliance Date

Although most provisions of the Final Rule became effective on March 26, many provisions impacting covered entities and business associates (including subcontractors) required compliance by Sept. 23. However, if certain conditions are met, the Final Rule allows additional time to revise business associate agreements to make them compliant. In particular, transition provisions will allow covered entities and business associates to continue to operate under existing business-associate agreements for up to one year beyond the compliance date (until Sept. 22, 2014) if the business-associate agreement:

1. Is in writing;
2. Is in place prior to Jan. 25, 2013 (the publication date of the Final Rule);
3. Is compliant with the Privacy and Security Rules, in effect immediately prior to Jan. 25, 2013; and
4. Is not modified or renewed.

This additional time for grandfathered business-associate agreements applies only to the written-documentation requirement. Covered entities, business associates and subcontractors will be required to comply with all other HIPAA requirements beginning on the compliance date, even if the business-associate agreement qualifies for grandfathered status

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Footnote

The exceptions relate to (i) unintentional, good-faith access, acquisition or use by members of the covered entity’s or business associate’s workforce, (ii) inadvertent disclosure limited to persons with authorized access and not resulting in further unpermitted use or disclosure, and (iii) good-faith belief that the unauthorized recipient would be unable to retain the PHI.

Key Takeaways for Hospitalist Groups

• Covered entities and business associates should review their business associate agreements and determine whether the agreements qualify for grandfathered status and, if needed, enter into new business-associate agreements.
• Covered entities and business associates will need to review their policies and procedures so that they can implement all necessary changes in a timely manner.
• Notices of Privacy Practices will need to be revised, and appropriate training should be provided to personnel of covered entities and business associates.
• Any vendor or business that performs functions for a covered entity or another business associate involving the use or disclosure of PHI should determine whether it is a “business associate” and, if so, what needs to be done in order to comply with the Final Rule.

On Jan. 17, 2013, the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) issued an omnibus Final Rule implementing various provisions of the Health Information Technology for Economic and Clinical Health, or HITECH, Act. The Final Rule revises the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the interim final Breach Notification Rule.

The HITECH Act, which took effect as part of the American Recovery and Reinvestment Act of 2009, expanded the obligations of covered entities and business associates to protect the confidentiality and security of protected health information (PHI).

Under HIPAA, “covered entities” may disclose PHI to “business associates,” and permit business associates to create and receive PHI on behalf of the covered entity, subject to the terms of a business-associate agreement between the parties. A “covered entity” is defined as a health plan, healthcare clearinghouse, or healthcare provider (e.g. physician practice or hospital) that transmits health information electronically. In general, the HIPAA regulations have traditionally defined a “business associate” as a person (other than a member of the covered entity’s workforce) or entity who, on behalf of a covered entity, performs a function or activity involving the use or disclosure of PHI, such as the performance of financial, legal, actuarial, accounting, consulting, data aggregation, management, administrative, or accreditation services to or for a covered entity.

Prior to the HITECH Act, business associates were contractually obligated to maintain the privacy and security of PHI but could not be sanctioned for failing to comply with HIPAA. The HITECH Act expands those obligations and exposure of business associates by:

1. Applying many of the privacy and security standards to business associates;
2. Subjecting business associates to the breach-notification requirements; and
3. Imposing civil and criminal penalties on business associates for HIPAA violations.

In addition, the HITECH Act strengthened the penalties and enforcement mechanisms under HIPAA and required periodic audits to ensure that covered entities and business associates are compliant.

Expansion of Breach-Notification Requirements

The Final Rule expands the breach-notification obligations of covered entities and business associates by revising the definition of “breach” and the risk-assessment process for determining whether notification is required. A use or disclosure of unsecured PHI that is not permitted under the Privacy Rule is presumed to be a breach (and therefore requires notification to the individual, OCR, and possibly the media) unless the incident satisfies an exception, or the covered entity or business associate demonstrates a low probability that PHI has been compromised.1 This risk analysis is based on at least the following four factors:

1. The nature and extent of the PHI, including the types of identifiers and the likelihood of re-identification;
2. The unauthorized person who used or accessed the PHI;
3. Whether the PHI was actually acquired or viewed; and
4. The extent to which the risk is mitigated (e.g. by obtaining reliable assurances by a recipient of PHI that the information will be destroyed or will not be used or disclosed).

Expansion of Business-Associate Obligations

The Final Rule implements the HITECH Act’s expansion of business associates’ HIPAA obligations by applying the Privacy and Security Rules directly to business associates and by imposing civil and criminal penalties on business associates for HIPAA violations. It also extends obligations and potential penalties to subcontractors of business associates if a business associate delegates a function, activity, or service to the subcontractor, and the subcontractor creates, receives, maintains, or transmits PHI on behalf of the business associate. Any business associate that delegates a function involving the use or disclosure of PHI to a subcontractor will be required to enter into a business-associate agreement with the subcontractor.

Additional Provisions

The Final Rule addresses the following additional issues by:

• Requiring covered entities to modify their Notices of Privacy Practices;
• Allowing individuals to obtain a copy of PHI in an electronic format if the covered entity uses an electronic health record;
• Restricting marketing activities;
• Allowing covered entities to disclose relevant PHI of a deceased person to a family member, close friend, or other person designated by the deceased, unless the disclosure is inconsistent with the deceased person’s known prior expressed preference;
• Requiring covered entities to agree to an individual’s request to restrict disclosure of PHI to a health plan when the individual (or someone other than the health plan) pays for the healthcare item or service in full;
• Revising the definition of PHI to exclude information about a person who has been deceased for more than 50 years;
• Prohibiting the sale of PHI without authorization from the individual, and adding a requirement of authorization in order for a covered entity to receive remuneration for disclosing PHI;
• Clarifying OCR’s view that covered entities are allowed to send electronic PHI to individuals in unencrypted e-mails only after notifying the individual of the risk;
• Prohibiting health plans from using or disclosing genetic information for underwriting, as required by the Genetic Information Nondiscrimination Act of 2008 (GINA);
• Allowing disclosure of proof of immunization to schools if agreed by the parent, guardian, or individual;
• Permitting compound authorizations for clinical-research studies; and
• Revising the Enforcement Rule (which was previously revised in 2009 as an interim Final Rule), which:

  • Requires the secretary of HHS to investigate a HIPAA complaint if a preliminary investigation indicates a possible violation due to willful neglect;
  • Permits HHS to disclose PHI to other government agencies (including state attorneys general) for civil or criminal law-enforcement purposes; and
  • Revises standards for determining the levels of civil money penalties.

Effective Date, Compliance Date

Although most provisions of the Final Rule became effective on March 26, many provisions impacting covered entities and business associates (including subcontractors) required compliance by Sept. 23. However, if certain conditions are met, the Final Rule allows additional time to revise business associate agreements to make them compliant. In particular, transition provisions will allow covered entities and business associates to continue to operate under existing business-associate agreements for up to one year beyond the compliance date (until Sept. 22, 2014) if the business-associate agreement:

1. Is in writing;
2. Is in place prior to Jan. 25, 2013 (the publication date of the Final Rule);
3. Is compliant with the Privacy and Security Rules, in effect immediately prior to Jan. 25, 2013; and
4. Is not modified or renewed.

This additional time for grandfathered business-associate agreements applies only to the written-documentation requirement. Covered entities, business associates and subcontractors will be required to comply with all other HIPAA requirements beginning on the compliance date, even if the business-associate agreement qualifies for grandfathered status

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Footnote

The exceptions relate to (i) unintentional, good-faith access, acquisition or use by members of the covered entity’s or business associate’s workforce, (ii) inadvertent disclosure limited to persons with authorized access and not resulting in further unpermitted use or disclosure, and (iii) good-faith belief that the unauthorized recipient would be unable to retain the PHI.

The proportion of U.S. hospitals projected to offer palliative-care programs by 2014, according to the most recent survey of the industry by the Center to Advance Palliative Care.⁷ The report estimates a 67% increase in palliative-care services at hospitals of 50 or more beds. The highest concentration for hospital-based palliative care is in the Northeast regions, with the lowest percentage in the South region.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

The proportion of U.S. hospitals projected to offer palliative-care programs by 2014, according to the most recent survey of the industry by the Center to Advance Palliative Care.⁷ The report estimates a 67% increase in palliative-care services at hospitals of 50 or more beds. The highest concentration for hospital-based palliative care is in the Northeast regions, with the lowest percentage in the South region.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

The proportion of U.S. hospitals projected to offer palliative-care programs by 2014, according to the most recent survey of the industry by the Center to Advance Palliative Care.⁷ The report estimates a 67% increase in palliative-care services at hospitals of 50 or more beds. The highest concentration for hospital-based palliative care is in the Northeast regions, with the lowest percentage in the South region.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Antibiotic resistance to hospital-acquired infections (HAIs) is rising at faster rates than predicted in 2008 by the Centers for Disease Control and Prevention (CDC), according to an analysis of privately gathered data reported in a recent commentary in Antimicrobial Agents and Chemotherapy, concluding that resistance is “at crisis levels.”³

Antibiotic-resistant microbes infect more than 2 million Americans each year and kill more than 100,000.

“We must act to find new weapons in the global battle against deadly superbugs,” particularly three common HAIs: acinetobacter, E. coli, and klebsiella, said co-author Brad Spellberg, MD, infectious-disease specialist at Harbor-UCLA Medical Center in Los Angeles.

A recent fact sheet from the Alliance for Aging Research notes that older patients, who represent 45% of HAIs annually, carry a higher burden of illness and less favorable outcomes than younger patients.⁴

Meanwhile, a study of the ICUs at 43 Hospital Corporation of America hospitals, published in the New England Journal of Medicine, provides support for treating all ICU patients with universal precautions for methicillin-resistant Staphylococcus aureus (MRSA).⁵ Washing all ICU patients with antibiotic soap and administering nasal antibiotics reduced all types of bloodstream infections by 44% and proved more effective than the common practice of screening patients for MRSA first, then treating those testing positive.

Another recent resource for HAIs is the “Eliminating Catheter-Associated Urinary Tract Infections” guide from the American Hospital Association’s Hospitals in Pursuit of Excellence unit.⁶ The booklet recommends an evidence-based, three-step action plan derived from AHA’s On the CUSP: Stop CAUTI project, and is available free on the AHA website. It has an accompanying webinar, which outlines the business case for eliminating catheter-associated urinary tract infections (CAUTIs) and the importance of hospital culture in achieving sustainability.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Antibiotic resistance to hospital-acquired infections (HAIs) is rising at faster rates than predicted in 2008 by the Centers for Disease Control and Prevention (CDC), according to an analysis of privately gathered data reported in a recent commentary in Antimicrobial Agents and Chemotherapy, concluding that resistance is “at crisis levels.”³

Antibiotic-resistant microbes infect more than 2 million Americans each year and kill more than 100,000.

“We must act to find new weapons in the global battle against deadly superbugs,” particularly three common HAIs: acinetobacter, E. coli, and klebsiella, said co-author Brad Spellberg, MD, infectious-disease specialist at Harbor-UCLA Medical Center in Los Angeles.

A recent fact sheet from the Alliance for Aging Research notes that older patients, who represent 45% of HAIs annually, carry a higher burden of illness and less favorable outcomes than younger patients.⁴

Meanwhile, a study of the ICUs at 43 Hospital Corporation of America hospitals, published in the New England Journal of Medicine, provides support for treating all ICU patients with universal precautions for methicillin-resistant Staphylococcus aureus (MRSA).⁵ Washing all ICU patients with antibiotic soap and administering nasal antibiotics reduced all types of bloodstream infections by 44% and proved more effective than the common practice of screening patients for MRSA first, then treating those testing positive.

Another recent resource for HAIs is the “Eliminating Catheter-Associated Urinary Tract Infections” guide from the American Hospital Association’s Hospitals in Pursuit of Excellence unit.⁶ The booklet recommends an evidence-based, three-step action plan derived from AHA’s On the CUSP: Stop CAUTI project, and is available free on the AHA website. It has an accompanying webinar, which outlines the business case for eliminating catheter-associated urinary tract infections (CAUTIs) and the importance of hospital culture in achieving sustainability.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Antibiotic resistance to hospital-acquired infections (HAIs) is rising at faster rates than predicted in 2008 by the Centers for Disease Control and Prevention (CDC), according to an analysis of privately gathered data reported in a recent commentary in Antimicrobial Agents and Chemotherapy, concluding that resistance is “at crisis levels.”³

Antibiotic-resistant microbes infect more than 2 million Americans each year and kill more than 100,000.

“We must act to find new weapons in the global battle against deadly superbugs,” particularly three common HAIs: acinetobacter, E. coli, and klebsiella, said co-author Brad Spellberg, MD, infectious-disease specialist at Harbor-UCLA Medical Center in Los Angeles.

A recent fact sheet from the Alliance for Aging Research notes that older patients, who represent 45% of HAIs annually, carry a higher burden of illness and less favorable outcomes than younger patients.⁴

Meanwhile, a study of the ICUs at 43 Hospital Corporation of America hospitals, published in the New England Journal of Medicine, provides support for treating all ICU patients with universal precautions for methicillin-resistant Staphylococcus aureus (MRSA).⁵ Washing all ICU patients with antibiotic soap and administering nasal antibiotics reduced all types of bloodstream infections by 44% and proved more effective than the common practice of screening patients for MRSA first, then treating those testing positive.

Another recent resource for HAIs is the “Eliminating Catheter-Associated Urinary Tract Infections” guide from the American Hospital Association’s Hospitals in Pursuit of Excellence unit.⁶ The booklet recommends an evidence-based, three-step action plan derived from AHA’s On the CUSP: Stop CAUTI project, and is available free on the AHA website. It has an accompanying webinar, which outlines the business case for eliminating catheter-associated urinary tract infections (CAUTIs) and the importance of hospital culture in achieving sustainability.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.² Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.

The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.

Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.

Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).

“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”

Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.² Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.

The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.

Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.

Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).

“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”

Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.² Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.

The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.

Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.

Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).

“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”

Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.

UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”¹

Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.

“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”

However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.

UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”¹

Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.

“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”

However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.

UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”¹

Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.

“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”

However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Editor’s note: This month’s KCQ first appeared in July 2009, and since that time it has been one of our website’s most-read articles, generating 23,000-plus pageviews.

Case

A previously healthy 55-year-old white female presents to the ED with a three-day history of pain and erythema in her right hand. Examination reveals fluctuance as well. She is diagnosed with an abscess with surrounding cellulitis. The abscess is incised, drained, and cultured, and she is sent home on oral trimethoprim/sulfamethoxazole. The following day, her cellulitis has worsened. She is hospitalized and commenced on intravenous vancomycin. What is the best empiric therapy for community-acquired cellulitis?

Background

Cellulitis is defined as a skin and soft-tissue infection (SSTI), which develops as a result of bacterial entry via breaches in the skin barrier. Typically, it involves the dermis and subcutaneous tissue and is associated with local tenderness, erythema, swelling and fever. Cellulitis usually affects the lower extremities, but it can affect other locations, resulting in diagnoses such as periorbital, abdominal wall, buccal, and perianal cellulitis.^1,2

Gram-positive organisms, especially Staphylococcus aureus and beta hemolytic streptococci, are the most common causes of cellulitis. Although it is less common, cellulitis can be caused by gram-negative organisms. The recent significant increase in the prevalence of SSTIs due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has led to changes in the selection of antibiotics that were most commonly utilized to empirically treat cellulitis.

The diagnosis of cellulitis is based primarily on clinical manifestations. Due to low diagnostic yields, blood cultures, needle aspiration, or punch biopsy specimens usually are not helpful in the setting of simple cellulitis.³ Therefore, antibiotic therapy is almost universally started empirically. Starting appropriate initial antibiotic therapy improves patient outcomes by reducing mortality rates, length of stay, and inpatient costs.⁴

Cellulitis incidence is about two cases per 1,000 patient-years.⁵ This rather high incidence, coupled with escalating rates of SSTIs due to CA-MRSA, demands reliable and cost-effective treatment strategies for the management of community-acquired cellulitis.

Review of the Data

The treatment of community-acquired cellulitis was straightforward until the past decade, as physicians saw a significant increase in CA-MRSA incidence.⁶ MRSA was reported initially in 1961, only two years after methicillin was introduced into clinical practice.^7,8 Subsequently, MRSA prevalence increased dramatically, and by the beginning of this decade, more than 50% of the Staphylococcus aureus hospital strains were resistant to methicillin.⁸ Furthermore, 60% to 80% of community-acquired Staphylococcus aureus strains in the U.S. are methicillin-resistant.⁸

The two major types of MRSA infections are healthcare-acquired (HA-MRSA) and community-acquired (CA-MRSA). The HA-MRSA infection group is further subdivided into those strains that develop during a period of hospitalization and those that develop following contact with healthcare facilities (e.g. hospitalization or surgery within the previous year). This subgroup includes HA-MRSA infections in hemodialysis patients, residents of long-term-care facilities, and individuals who have a vascular catheter or other indwelling device.^9,10

CA-MRSA infections, on the other hand, occur in individuals who have not had any contact with healthcare facilities. Higher rates of CA-MRSA infection are observed in settings where individuals have close contact with each other, including military trainees, athletes involved in contact sports, patients age 65 and older, men who have sex with other men, and parenteral substance abusers.^8,11-13 However, in view of the high prevalence of CA-MRSA in the U.S., most patients, including those without any apparent risk factors, are at risk.⁸

HA-MRSA has the ability to survive on inanimate objects for extended time periods, increasing the likelihood of transmission to persons who come into contact with those objects. Although evidence has not confirmed that CA-MRSA has a similar capacity, it seems plausible that such spread does contribute to the propagation of CA-MRSA.¹²

The increasing importance of CA-MRSA also is evident in hospital settings, where it is replacing HA-MRSA as the most common type of Staphylococcus aureus. Because CA-MRSA tends to be susceptible to a larger number of antibiotics than HA-MRSA is, this has led to a reduced incidence of multidrug resistance. Fortunately, unlike HA-MRSA, CA-MRSA is susceptible to non-beta-lactam antibiotics, including tetracyclines, sulfonamides, and clindamycin.⁹

CA-MRSA most often causes SSTIs, and a tender abscess is a typical presentation.⁸ Patients commonly misinterpret early skin lesions as an insect or spider bite.^12,14 When cutaneous CA-MRSA presents as an abscess, an incision and drainage procedure is essential for adequate treatment of the infection. For some CA-MRSA infections, particularly those characterized by the presence of a relatively small abscess, it might be adequate to do only an incision and drainage procedure, and not administer antibiotics.^8,15 However, in most instances, especially when there is an area of cellulitis around the abscess, the initiation of antibiotic therapy improves patients’ clinical outcomes.^9,16

When there is no apparent drainable purulent fluid collection, which often occurs with cellulitis, antibiotics should be the mainstay of therapy. The decision about which antibiotic to start can present some challenges, because the organism causing the cellulitis usually is not identified. This is because blood cultures are positive in less than 5% of cases. Also, positive culture results from needle aspiration are only helpful 5% to 40% of the time. Meanwhile, culture of punch biopsy specimens yields a pathogen in only 20% to 30% of cases.^3,17-19

Due to increased CA-MRSA incidence, cephalexin should not be prescribed to treat cellulitis in the outpatient setting because it does not provide coverage for the pathogen.¹³ Instead, oral antibiotics (e.g. clindamycin or trimethoprim/sulfamethoxazole) should be prescribed. Doxycycline, minocycline, rifampin (usually prescribed in combination with fusidic acid to prevent resistance development), and linezolid are additional therapeutic options.

Trimethoprim/sulfamethoxazole and clindamycin have several advantages: good oral bioavailability, familiarity to physicians, and general affordability. A disadvantage to using both trimethoprim/sulfamethoxazole and doxycycline is that they provide inadequate coverage for group A streptococci, which are a common cause of cellulitis. Therefore, the simultaneous use of a beta-lactam antibiotic with either of these medications may improve outcomes for “nonpurulent” cellulitis.^13,15 Linezolid has proven effective for SSTIs caused by MRSA, even though it is not bactericidal.

Excellent oral bioavailability of this drug is an attractive characteristic, as it facilitates the transition from the use of intravenous to oral antibiotic therapy later in a patient’s hospital course. Although oral linezolid has been studied in clinical trials and provides good coverage for MRSA, its use in the outpatient setting is relatively limited, largely due to its significant cost.²⁰ In 2008, the cost of 10 days of treatment with oral linezolid was $1,286.80. In comparison, the generic trimethoprim/sulfamethoxazole cost $9.40, and generic clindamycin cost $95.10.⁸ The lack of routine availability in many outpatient pharmacies also hinders the widespread use of linezolid.¹³

To date, with the exception of linezolid, no randomized prospective clinical trials clearly demonstrate the efficacy of the oral agents that are commonly used for the outpatient treatment of cellulitis.²⁰

When patients require hospitalization for the optimal treatment of cellulitis, it is important to select a parenteral antibiotic that provides coverage for MRSA.⁸ Vancomycin, daptomycin, linezolid, and tigecycline are the most commonly used agents.⁶

In the inpatient setting, failure to initiate appropriate medical therapy can result in longer hospital admissions, which significantly increase inpatient costs. Inadequate antibiotic therapy creates a significant financial burden and has been associated with increased mortality.⁴ Historically, vancomycin is used whenever a MRSA infection is suspected. However, there is concern about the declining efficacy of vancomycin related to a gradual increase in the rate of relative resistance—a minimal inhibitory concentration (MIC) increase—in MRSA strains. This MIC creep is noted in some medical centers and can lead to a failure to respond to vancomycin.^13,20

Daptomycin is rapidly bactericidal against MRSA; in some institutions, its use may be preferred over vancomycin because the former antibiotic is associated with a significantly more rapid clinical response, which may shorten the required length of hospitalization.²¹ The once-daily dosing requirement for daptomycin allows for ease of use in both hospital and outpatient settings, and therefore may facilitate early hospital discharge or prevent the need for hospitalization altogether. Clinical experience also suggests potential economic advantages with the use of daptomycin.²²

Tigecycline is a bacteriostatic antibiotic that achieves low serum concentrations. However, it penetrates the skin well and has a similar effectiveness to combination therapy with vancomycin and aztreonam. Thus far, tigecycline is not widely used for the treatment of MRSA infections, and it has been suggested that it may be preferred for polymicrobial infections or for patients who exhibit allergies to more commonly used agents.⁸

When selecting an antibiotic therapy, cost considerations play an important role in the decision-making process. For intravenous agents commonly used to treat CA-MRSA infections, the 2008 cost for 10 days of treatment with generic vancomycin was $182.80; daptomycin cost $1,660.80. For tigecycline and linezolid, the same duration of treatment cost $1,362 and $1,560, respectively.⁸

Back to the Case

Our patient, an otherwise healthy female, presented with no apparent risk factors for developing a CA-MRSA SSTI. However, more detailed history revealed that she regularly used sports equipment at her local fitness center. Based on her clinical presentation and concerns about the high local prevalence of CA-MRSA, an incision and drainage procedure was performed, and she was started empirically on IV vancomycin. She had a positive clinical response to this treatment.

Wound culture results confirmed CA-MRSA abscess and cellulitis, susceptible to trimethoprim/sulfamethoxazole. She was discharged on the oral formulation of this antibiotic to complete a 10-day course of treatment, including the days she received intravenous antibiotics.

Few well-designed trials have compared different lengths of cellulitis therapy. Most authorities recommend five to 10 days of treatment; however, longer courses might be required for more severe or complicated diseases.

Bottom line

Because of the high prevalence of CA-MRSA, initial antibiotic therapy for the treatment of community-acquired cellulitis must provide coverage for this organism.

Dr. Clarke is a hospitalist and assistant professor of medicine at Emory University School of Medicine, Atlanta. Dr. Dressler is a professor of medicine, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program. Dr. Purohit, formerly an instructor in clinical medicine at Emory, is a hospitalist at WakeMed Health and Hospitals in Raleigh, N.C.

References

1. Barzilai A, Choen HA. Isolation of group A streptococci from children with perianal cellulitis and from their siblings. Pediatr Infect Dis J. 1998;17(4):358-360.
2. Thorsteinsdottir B, Tleyjeh IM, Baddour LM. Abdominal wall cellulitis in the morbidly obese. Scand J Infect Dis. 2005;37(8):605-608.
3. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-912.
4. Edelsberg J, Berger A, Weber DJ, et al. Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections. Infect Control Hosp Epidemiol. 2008;29(2):160-169.
5. McNamara DR, Tleyjeh IM, Berbari EF, et al. Incidence of lower extremity cellulitis: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2007;82(7):817-821.
6. Moellering RC. Current treatment options for community-acquired methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46(7):1032-1037.
7. Chambers HF. The changing epidemiology of Staphylococcus aureus. Emerg Infect Dis. 2001;7(2):178-182.
8. Moellering RC. A 39-year-old man with a skin infection. JAMA. 2008;299(1):79-87.
9. Ruhe J, Smith N, Bradsher RW, Menon A. Community-onset methicillin-resistant Staphylococcus aureus skin and soft tissue infections: impact of antimicrobial therapy on outcome. Clin Infect Dis. 2007;44(6):777-784.
10. David MZ, Glikman D, Crawford SE, et al. What is community-associated methicillin-resistant Staphylococcus aureus? J Infect Dis. 2008;197(9):1235-1243.
11. Iyer S, Jones DH. Community-acquired methicillin-resistant Staphylococcus aureus skin infection: a retrospective analysis of clinical presentation and treatment of a local outbreak. J Am Acad Dermatol. 2004;50(6):854-858.
12. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus skin or soft tissue infections in a state prison—Mississippi, 2000. MMWR Morb Mortal Wkly Rep. 2001;50(42):919-922.
13. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-390.
14. Dominguez TJ. It’s not a spider bite, it’s community-acquired methicillin-resistant Staphylococcus aureus. J Am Board Fam Pract. 2004;17(3):220-226.
15. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-674.
16. Jetton L. Therapy for methicillin-resistant Staphylococcus aureus. N Engl J Med. 2006;355(20):2153-2155.
17. Hook EW, Hooton TM, Horton CA, et al. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med. 1986;146(2):295-297. Duvanel T, Auckenthaler R, Rohner P, Harms M,
18. Saurat JH. Quantitative cultures of biopsy specimens from cutaneous cellulitis. Arch Intern Med. 1989;149(2):293-296.
19. Newell PM, Norden CW. Value of needle aspiration in bacteriologic diagnosis of cellulitis in adults. J Clin Microbiol. 1988; 26(3):401-404.
20. Loffler CA, Macdougall C. Update on prevalence and treatment of methicillin-resistant Staphylococcus aureus infections. Expert Rev Anti Infect Ther. 2007;5(6):961-981.
21. Davis SL, McKinnon PS, Hall LM, et al. Daptomycin versus vancomycin for complicated skin and skin structure infections: clinical and economic outcomes. Pharmacotherapy. 2007;27(12):1611-1618.
22. Seaton RA. Daptomycin: rationale and role in the management of skin and soft tissue infections. J Antimicrob Chemother. 2008;62(Suppl 3):iii15-23.

Editor’s note: This month’s KCQ first appeared in July 2009, and since that time it has been one of our website’s most-read articles, generating 23,000-plus pageviews.

Case

A previously healthy 55-year-old white female presents to the ED with a three-day history of pain and erythema in her right hand. Examination reveals fluctuance as well. She is diagnosed with an abscess with surrounding cellulitis. The abscess is incised, drained, and cultured, and she is sent home on oral trimethoprim/sulfamethoxazole. The following day, her cellulitis has worsened. She is hospitalized and commenced on intravenous vancomycin. What is the best empiric therapy for community-acquired cellulitis?

Background

Cellulitis is defined as a skin and soft-tissue infection (SSTI), which develops as a result of bacterial entry via breaches in the skin barrier. Typically, it involves the dermis and subcutaneous tissue and is associated with local tenderness, erythema, swelling and fever. Cellulitis usually affects the lower extremities, but it can affect other locations, resulting in diagnoses such as periorbital, abdominal wall, buccal, and perianal cellulitis.^1,2

Gram-positive organisms, especially Staphylococcus aureus and beta hemolytic streptococci, are the most common causes of cellulitis. Although it is less common, cellulitis can be caused by gram-negative organisms. The recent significant increase in the prevalence of SSTIs due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has led to changes in the selection of antibiotics that were most commonly utilized to empirically treat cellulitis.

The diagnosis of cellulitis is based primarily on clinical manifestations. Due to low diagnostic yields, blood cultures, needle aspiration, or punch biopsy specimens usually are not helpful in the setting of simple cellulitis.³ Therefore, antibiotic therapy is almost universally started empirically. Starting appropriate initial antibiotic therapy improves patient outcomes by reducing mortality rates, length of stay, and inpatient costs.⁴

Cellulitis incidence is about two cases per 1,000 patient-years.⁵ This rather high incidence, coupled with escalating rates of SSTIs due to CA-MRSA, demands reliable and cost-effective treatment strategies for the management of community-acquired cellulitis.

Review of the Data

The treatment of community-acquired cellulitis was straightforward until the past decade, as physicians saw a significant increase in CA-MRSA incidence.⁶ MRSA was reported initially in 1961, only two years after methicillin was introduced into clinical practice.^7,8 Subsequently, MRSA prevalence increased dramatically, and by the beginning of this decade, more than 50% of the Staphylococcus aureus hospital strains were resistant to methicillin.⁸ Furthermore, 60% to 80% of community-acquired Staphylococcus aureus strains in the U.S. are methicillin-resistant.⁸

The two major types of MRSA infections are healthcare-acquired (HA-MRSA) and community-acquired (CA-MRSA). The HA-MRSA infection group is further subdivided into those strains that develop during a period of hospitalization and those that develop following contact with healthcare facilities (e.g. hospitalization or surgery within the previous year). This subgroup includes HA-MRSA infections in hemodialysis patients, residents of long-term-care facilities, and individuals who have a vascular catheter or other indwelling device.^9,10

CA-MRSA infections, on the other hand, occur in individuals who have not had any contact with healthcare facilities. Higher rates of CA-MRSA infection are observed in settings where individuals have close contact with each other, including military trainees, athletes involved in contact sports, patients age 65 and older, men who have sex with other men, and parenteral substance abusers.^8,11-13 However, in view of the high prevalence of CA-MRSA in the U.S., most patients, including those without any apparent risk factors, are at risk.⁸

HA-MRSA has the ability to survive on inanimate objects for extended time periods, increasing the likelihood of transmission to persons who come into contact with those objects. Although evidence has not confirmed that CA-MRSA has a similar capacity, it seems plausible that such spread does contribute to the propagation of CA-MRSA.¹²

The increasing importance of CA-MRSA also is evident in hospital settings, where it is replacing HA-MRSA as the most common type of Staphylococcus aureus. Because CA-MRSA tends to be susceptible to a larger number of antibiotics than HA-MRSA is, this has led to a reduced incidence of multidrug resistance. Fortunately, unlike HA-MRSA, CA-MRSA is susceptible to non-beta-lactam antibiotics, including tetracyclines, sulfonamides, and clindamycin.⁹

CA-MRSA most often causes SSTIs, and a tender abscess is a typical presentation.⁸ Patients commonly misinterpret early skin lesions as an insect or spider bite.^12,14 When cutaneous CA-MRSA presents as an abscess, an incision and drainage procedure is essential for adequate treatment of the infection. For some CA-MRSA infections, particularly those characterized by the presence of a relatively small abscess, it might be adequate to do only an incision and drainage procedure, and not administer antibiotics.^8,15 However, in most instances, especially when there is an area of cellulitis around the abscess, the initiation of antibiotic therapy improves patients’ clinical outcomes.^9,16

When there is no apparent drainable purulent fluid collection, which often occurs with cellulitis, antibiotics should be the mainstay of therapy. The decision about which antibiotic to start can present some challenges, because the organism causing the cellulitis usually is not identified. This is because blood cultures are positive in less than 5% of cases. Also, positive culture results from needle aspiration are only helpful 5% to 40% of the time. Meanwhile, culture of punch biopsy specimens yields a pathogen in only 20% to 30% of cases.^3,17-19

Due to increased CA-MRSA incidence, cephalexin should not be prescribed to treat cellulitis in the outpatient setting because it does not provide coverage for the pathogen.¹³ Instead, oral antibiotics (e.g. clindamycin or trimethoprim/sulfamethoxazole) should be prescribed. Doxycycline, minocycline, rifampin (usually prescribed in combination with fusidic acid to prevent resistance development), and linezolid are additional therapeutic options.

Trimethoprim/sulfamethoxazole and clindamycin have several advantages: good oral bioavailability, familiarity to physicians, and general affordability. A disadvantage to using both trimethoprim/sulfamethoxazole and doxycycline is that they provide inadequate coverage for group A streptococci, which are a common cause of cellulitis. Therefore, the simultaneous use of a beta-lactam antibiotic with either of these medications may improve outcomes for “nonpurulent” cellulitis.^13,15 Linezolid has proven effective for SSTIs caused by MRSA, even though it is not bactericidal.

Excellent oral bioavailability of this drug is an attractive characteristic, as it facilitates the transition from the use of intravenous to oral antibiotic therapy later in a patient’s hospital course. Although oral linezolid has been studied in clinical trials and provides good coverage for MRSA, its use in the outpatient setting is relatively limited, largely due to its significant cost.²⁰ In 2008, the cost of 10 days of treatment with oral linezolid was $1,286.80. In comparison, the generic trimethoprim/sulfamethoxazole cost $9.40, and generic clindamycin cost $95.10.⁸ The lack of routine availability in many outpatient pharmacies also hinders the widespread use of linezolid.¹³

To date, with the exception of linezolid, no randomized prospective clinical trials clearly demonstrate the efficacy of the oral agents that are commonly used for the outpatient treatment of cellulitis.²⁰

When patients require hospitalization for the optimal treatment of cellulitis, it is important to select a parenteral antibiotic that provides coverage for MRSA.⁸ Vancomycin, daptomycin, linezolid, and tigecycline are the most commonly used agents.⁶

In the inpatient setting, failure to initiate appropriate medical therapy can result in longer hospital admissions, which significantly increase inpatient costs. Inadequate antibiotic therapy creates a significant financial burden and has been associated with increased mortality.⁴ Historically, vancomycin is used whenever a MRSA infection is suspected. However, there is concern about the declining efficacy of vancomycin related to a gradual increase in the rate of relative resistance—a minimal inhibitory concentration (MIC) increase—in MRSA strains. This MIC creep is noted in some medical centers and can lead to a failure to respond to vancomycin.^13,20

Daptomycin is rapidly bactericidal against MRSA; in some institutions, its use may be preferred over vancomycin because the former antibiotic is associated with a significantly more rapid clinical response, which may shorten the required length of hospitalization.²¹ The once-daily dosing requirement for daptomycin allows for ease of use in both hospital and outpatient settings, and therefore may facilitate early hospital discharge or prevent the need for hospitalization altogether. Clinical experience also suggests potential economic advantages with the use of daptomycin.²²

Tigecycline is a bacteriostatic antibiotic that achieves low serum concentrations. However, it penetrates the skin well and has a similar effectiveness to combination therapy with vancomycin and aztreonam. Thus far, tigecycline is not widely used for the treatment of MRSA infections, and it has been suggested that it may be preferred for polymicrobial infections or for patients who exhibit allergies to more commonly used agents.⁸

When selecting an antibiotic therapy, cost considerations play an important role in the decision-making process. For intravenous agents commonly used to treat CA-MRSA infections, the 2008 cost for 10 days of treatment with generic vancomycin was $182.80; daptomycin cost $1,660.80. For tigecycline and linezolid, the same duration of treatment cost $1,362 and $1,560, respectively.⁸

Back to the Case

Our patient, an otherwise healthy female, presented with no apparent risk factors for developing a CA-MRSA SSTI. However, more detailed history revealed that she regularly used sports equipment at her local fitness center. Based on her clinical presentation and concerns about the high local prevalence of CA-MRSA, an incision and drainage procedure was performed, and she was started empirically on IV vancomycin. She had a positive clinical response to this treatment.

Wound culture results confirmed CA-MRSA abscess and cellulitis, susceptible to trimethoprim/sulfamethoxazole. She was discharged on the oral formulation of this antibiotic to complete a 10-day course of treatment, including the days she received intravenous antibiotics.

Few well-designed trials have compared different lengths of cellulitis therapy. Most authorities recommend five to 10 days of treatment; however, longer courses might be required for more severe or complicated diseases.

Bottom line

Because of the high prevalence of CA-MRSA, initial antibiotic therapy for the treatment of community-acquired cellulitis must provide coverage for this organism.

Dr. Clarke is a hospitalist and assistant professor of medicine at Emory University School of Medicine, Atlanta. Dr. Dressler is a professor of medicine, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program. Dr. Purohit, formerly an instructor in clinical medicine at Emory, is a hospitalist at WakeMed Health and Hospitals in Raleigh, N.C.

References

1. Barzilai A, Choen HA. Isolation of group A streptococci from children with perianal cellulitis and from their siblings. Pediatr Infect Dis J. 1998;17(4):358-360.
2. Thorsteinsdottir B, Tleyjeh IM, Baddour LM. Abdominal wall cellulitis in the morbidly obese. Scand J Infect Dis. 2005;37(8):605-608.
3. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-912.
4. Edelsberg J, Berger A, Weber DJ, et al. Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections. Infect Control Hosp Epidemiol. 2008;29(2):160-169.
5. McNamara DR, Tleyjeh IM, Berbari EF, et al. Incidence of lower extremity cellulitis: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2007;82(7):817-821.
6. Moellering RC. Current treatment options for community-acquired methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46(7):1032-1037.
7. Chambers HF. The changing epidemiology of Staphylococcus aureus. Emerg Infect Dis. 2001;7(2):178-182.
8. Moellering RC. A 39-year-old man with a skin infection. JAMA. 2008;299(1):79-87.
9. Ruhe J, Smith N, Bradsher RW, Menon A. Community-onset methicillin-resistant Staphylococcus aureus skin and soft tissue infections: impact of antimicrobial therapy on outcome. Clin Infect Dis. 2007;44(6):777-784.
10. David MZ, Glikman D, Crawford SE, et al. What is community-associated methicillin-resistant Staphylococcus aureus? J Infect Dis. 2008;197(9):1235-1243.
11. Iyer S, Jones DH. Community-acquired methicillin-resistant Staphylococcus aureus skin infection: a retrospective analysis of clinical presentation and treatment of a local outbreak. J Am Acad Dermatol. 2004;50(6):854-858.
12. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus skin or soft tissue infections in a state prison—Mississippi, 2000. MMWR Morb Mortal Wkly Rep. 2001;50(42):919-922.
13. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-390.
14. Dominguez TJ. It’s not a spider bite, it’s community-acquired methicillin-resistant Staphylococcus aureus. J Am Board Fam Pract. 2004;17(3):220-226.
15. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-674.
16. Jetton L. Therapy for methicillin-resistant Staphylococcus aureus. N Engl J Med. 2006;355(20):2153-2155.
17. Hook EW, Hooton TM, Horton CA, et al. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med. 1986;146(2):295-297. Duvanel T, Auckenthaler R, Rohner P, Harms M,
18. Saurat JH. Quantitative cultures of biopsy specimens from cutaneous cellulitis. Arch Intern Med. 1989;149(2):293-296.
19. Newell PM, Norden CW. Value of needle aspiration in bacteriologic diagnosis of cellulitis in adults. J Clin Microbiol. 1988; 26(3):401-404.
20. Loffler CA, Macdougall C. Update on prevalence and treatment of methicillin-resistant Staphylococcus aureus infections. Expert Rev Anti Infect Ther. 2007;5(6):961-981.
21. Davis SL, McKinnon PS, Hall LM, et al. Daptomycin versus vancomycin for complicated skin and skin structure infections: clinical and economic outcomes. Pharmacotherapy. 2007;27(12):1611-1618.
22. Seaton RA. Daptomycin: rationale and role in the management of skin and soft tissue infections. J Antimicrob Chemother. 2008;62(Suppl 3):iii15-23.

Editor’s note: This month’s KCQ first appeared in July 2009, and since that time it has been one of our website’s most-read articles, generating 23,000-plus pageviews.

Case

A previously healthy 55-year-old white female presents to the ED with a three-day history of pain and erythema in her right hand. Examination reveals fluctuance as well. She is diagnosed with an abscess with surrounding cellulitis. The abscess is incised, drained, and cultured, and she is sent home on oral trimethoprim/sulfamethoxazole. The following day, her cellulitis has worsened. She is hospitalized and commenced on intravenous vancomycin. What is the best empiric therapy for community-acquired cellulitis?

Background

Cellulitis is defined as a skin and soft-tissue infection (SSTI), which develops as a result of bacterial entry via breaches in the skin barrier. Typically, it involves the dermis and subcutaneous tissue and is associated with local tenderness, erythema, swelling and fever. Cellulitis usually affects the lower extremities, but it can affect other locations, resulting in diagnoses such as periorbital, abdominal wall, buccal, and perianal cellulitis.^1,2

Gram-positive organisms, especially Staphylococcus aureus and beta hemolytic streptococci, are the most common causes of cellulitis. Although it is less common, cellulitis can be caused by gram-negative organisms. The recent significant increase in the prevalence of SSTIs due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has led to changes in the selection of antibiotics that were most commonly utilized to empirically treat cellulitis.

The diagnosis of cellulitis is based primarily on clinical manifestations. Due to low diagnostic yields, blood cultures, needle aspiration, or punch biopsy specimens usually are not helpful in the setting of simple cellulitis.³ Therefore, antibiotic therapy is almost universally started empirically. Starting appropriate initial antibiotic therapy improves patient outcomes by reducing mortality rates, length of stay, and inpatient costs.⁴

Cellulitis incidence is about two cases per 1,000 patient-years.⁵ This rather high incidence, coupled with escalating rates of SSTIs due to CA-MRSA, demands reliable and cost-effective treatment strategies for the management of community-acquired cellulitis.

Review of the Data

The treatment of community-acquired cellulitis was straightforward until the past decade, as physicians saw a significant increase in CA-MRSA incidence.⁶ MRSA was reported initially in 1961, only two years after methicillin was introduced into clinical practice.^7,8 Subsequently, MRSA prevalence increased dramatically, and by the beginning of this decade, more than 50% of the Staphylococcus aureus hospital strains were resistant to methicillin.⁸ Furthermore, 60% to 80% of community-acquired Staphylococcus aureus strains in the U.S. are methicillin-resistant.⁸

The two major types of MRSA infections are healthcare-acquired (HA-MRSA) and community-acquired (CA-MRSA). The HA-MRSA infection group is further subdivided into those strains that develop during a period of hospitalization and those that develop following contact with healthcare facilities (e.g. hospitalization or surgery within the previous year). This subgroup includes HA-MRSA infections in hemodialysis patients, residents of long-term-care facilities, and individuals who have a vascular catheter or other indwelling device.^9,10

CA-MRSA infections, on the other hand, occur in individuals who have not had any contact with healthcare facilities. Higher rates of CA-MRSA infection are observed in settings where individuals have close contact with each other, including military trainees, athletes involved in contact sports, patients age 65 and older, men who have sex with other men, and parenteral substance abusers.^8,11-13 However, in view of the high prevalence of CA-MRSA in the U.S., most patients, including those without any apparent risk factors, are at risk.⁸

HA-MRSA has the ability to survive on inanimate objects for extended time periods, increasing the likelihood of transmission to persons who come into contact with those objects. Although evidence has not confirmed that CA-MRSA has a similar capacity, it seems plausible that such spread does contribute to the propagation of CA-MRSA.¹²

The increasing importance of CA-MRSA also is evident in hospital settings, where it is replacing HA-MRSA as the most common type of Staphylococcus aureus. Because CA-MRSA tends to be susceptible to a larger number of antibiotics than HA-MRSA is, this has led to a reduced incidence of multidrug resistance. Fortunately, unlike HA-MRSA, CA-MRSA is susceptible to non-beta-lactam antibiotics, including tetracyclines, sulfonamides, and clindamycin.⁹

CA-MRSA most often causes SSTIs, and a tender abscess is a typical presentation.⁸ Patients commonly misinterpret early skin lesions as an insect or spider bite.^12,14 When cutaneous CA-MRSA presents as an abscess, an incision and drainage procedure is essential for adequate treatment of the infection. For some CA-MRSA infections, particularly those characterized by the presence of a relatively small abscess, it might be adequate to do only an incision and drainage procedure, and not administer antibiotics.^8,15 However, in most instances, especially when there is an area of cellulitis around the abscess, the initiation of antibiotic therapy improves patients’ clinical outcomes.^9,16

When there is no apparent drainable purulent fluid collection, which often occurs with cellulitis, antibiotics should be the mainstay of therapy. The decision about which antibiotic to start can present some challenges, because the organism causing the cellulitis usually is not identified. This is because blood cultures are positive in less than 5% of cases. Also, positive culture results from needle aspiration are only helpful 5% to 40% of the time. Meanwhile, culture of punch biopsy specimens yields a pathogen in only 20% to 30% of cases.^3,17-19

Due to increased CA-MRSA incidence, cephalexin should not be prescribed to treat cellulitis in the outpatient setting because it does not provide coverage for the pathogen.¹³ Instead, oral antibiotics (e.g. clindamycin or trimethoprim/sulfamethoxazole) should be prescribed. Doxycycline, minocycline, rifampin (usually prescribed in combination with fusidic acid to prevent resistance development), and linezolid are additional therapeutic options.

Trimethoprim/sulfamethoxazole and clindamycin have several advantages: good oral bioavailability, familiarity to physicians, and general affordability. A disadvantage to using both trimethoprim/sulfamethoxazole and doxycycline is that they provide inadequate coverage for group A streptococci, which are a common cause of cellulitis. Therefore, the simultaneous use of a beta-lactam antibiotic with either of these medications may improve outcomes for “nonpurulent” cellulitis.^13,15 Linezolid has proven effective for SSTIs caused by MRSA, even though it is not bactericidal.

Excellent oral bioavailability of this drug is an attractive characteristic, as it facilitates the transition from the use of intravenous to oral antibiotic therapy later in a patient’s hospital course. Although oral linezolid has been studied in clinical trials and provides good coverage for MRSA, its use in the outpatient setting is relatively limited, largely due to its significant cost.²⁰ In 2008, the cost of 10 days of treatment with oral linezolid was $1,286.80. In comparison, the generic trimethoprim/sulfamethoxazole cost $9.40, and generic clindamycin cost $95.10.⁸ The lack of routine availability in many outpatient pharmacies also hinders the widespread use of linezolid.¹³

To date, with the exception of linezolid, no randomized prospective clinical trials clearly demonstrate the efficacy of the oral agents that are commonly used for the outpatient treatment of cellulitis.²⁰

When patients require hospitalization for the optimal treatment of cellulitis, it is important to select a parenteral antibiotic that provides coverage for MRSA.⁸ Vancomycin, daptomycin, linezolid, and tigecycline are the most commonly used agents.⁶

In the inpatient setting, failure to initiate appropriate medical therapy can result in longer hospital admissions, which significantly increase inpatient costs. Inadequate antibiotic therapy creates a significant financial burden and has been associated with increased mortality.⁴ Historically, vancomycin is used whenever a MRSA infection is suspected. However, there is concern about the declining efficacy of vancomycin related to a gradual increase in the rate of relative resistance—a minimal inhibitory concentration (MIC) increase—in MRSA strains. This MIC creep is noted in some medical centers and can lead to a failure to respond to vancomycin.^13,20

Daptomycin is rapidly bactericidal against MRSA; in some institutions, its use may be preferred over vancomycin because the former antibiotic is associated with a significantly more rapid clinical response, which may shorten the required length of hospitalization.²¹ The once-daily dosing requirement for daptomycin allows for ease of use in both hospital and outpatient settings, and therefore may facilitate early hospital discharge or prevent the need for hospitalization altogether. Clinical experience also suggests potential economic advantages with the use of daptomycin.²²

Tigecycline is a bacteriostatic antibiotic that achieves low serum concentrations. However, it penetrates the skin well and has a similar effectiveness to combination therapy with vancomycin and aztreonam. Thus far, tigecycline is not widely used for the treatment of MRSA infections, and it has been suggested that it may be preferred for polymicrobial infections or for patients who exhibit allergies to more commonly used agents.⁸

When selecting an antibiotic therapy, cost considerations play an important role in the decision-making process. For intravenous agents commonly used to treat CA-MRSA infections, the 2008 cost for 10 days of treatment with generic vancomycin was $182.80; daptomycin cost $1,660.80. For tigecycline and linezolid, the same duration of treatment cost $1,362 and $1,560, respectively.⁸

Back to the Case

Our patient, an otherwise healthy female, presented with no apparent risk factors for developing a CA-MRSA SSTI. However, more detailed history revealed that she regularly used sports equipment at her local fitness center. Based on her clinical presentation and concerns about the high local prevalence of CA-MRSA, an incision and drainage procedure was performed, and she was started empirically on IV vancomycin. She had a positive clinical response to this treatment.

Wound culture results confirmed CA-MRSA abscess and cellulitis, susceptible to trimethoprim/sulfamethoxazole. She was discharged on the oral formulation of this antibiotic to complete a 10-day course of treatment, including the days she received intravenous antibiotics.

Few well-designed trials have compared different lengths of cellulitis therapy. Most authorities recommend five to 10 days of treatment; however, longer courses might be required for more severe or complicated diseases.

Bottom line

Because of the high prevalence of CA-MRSA, initial antibiotic therapy for the treatment of community-acquired cellulitis must provide coverage for this organism.

Dr. Clarke is a hospitalist and assistant professor of medicine at Emory University School of Medicine, Atlanta. Dr. Dressler is a professor of medicine, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program. Dr. Purohit, formerly an instructor in clinical medicine at Emory, is a hospitalist at WakeMed Health and Hospitals in Raleigh, N.C.

References

1. Barzilai A, Choen HA. Isolation of group A streptococci from children with perianal cellulitis and from their siblings. Pediatr Infect Dis J. 1998;17(4):358-360.
2. Thorsteinsdottir B, Tleyjeh IM, Baddour LM. Abdominal wall cellulitis in the morbidly obese. Scand J Infect Dis. 2005;37(8):605-608.
3. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-912.
4. Edelsberg J, Berger A, Weber DJ, et al. Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections. Infect Control Hosp Epidemiol. 2008;29(2):160-169.
5. McNamara DR, Tleyjeh IM, Berbari EF, et al. Incidence of lower extremity cellulitis: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2007;82(7):817-821.
6. Moellering RC. Current treatment options for community-acquired methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46(7):1032-1037.
7. Chambers HF. The changing epidemiology of Staphylococcus aureus. Emerg Infect Dis. 2001;7(2):178-182.
8. Moellering RC. A 39-year-old man with a skin infection. JAMA. 2008;299(1):79-87.
9. Ruhe J, Smith N, Bradsher RW, Menon A. Community-onset methicillin-resistant Staphylococcus aureus skin and soft tissue infections: impact of antimicrobial therapy on outcome. Clin Infect Dis. 2007;44(6):777-784.
10. David MZ, Glikman D, Crawford SE, et al. What is community-associated methicillin-resistant Staphylococcus aureus? J Infect Dis. 2008;197(9):1235-1243.
11. Iyer S, Jones DH. Community-acquired methicillin-resistant Staphylococcus aureus skin infection: a retrospective analysis of clinical presentation and treatment of a local outbreak. J Am Acad Dermatol. 2004;50(6):854-858.
12. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus skin or soft tissue infections in a state prison—Mississippi, 2000. MMWR Morb Mortal Wkly Rep. 2001;50(42):919-922.
13. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-390.
14. Dominguez TJ. It’s not a spider bite, it’s community-acquired methicillin-resistant Staphylococcus aureus. J Am Board Fam Pract. 2004;17(3):220-226.
15. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-674.
16. Jetton L. Therapy for methicillin-resistant Staphylococcus aureus. N Engl J Med. 2006;355(20):2153-2155.
17. Hook EW, Hooton TM, Horton CA, et al. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med. 1986;146(2):295-297. Duvanel T, Auckenthaler R, Rohner P, Harms M,
18. Saurat JH. Quantitative cultures of biopsy specimens from cutaneous cellulitis. Arch Intern Med. 1989;149(2):293-296.
19. Newell PM, Norden CW. Value of needle aspiration in bacteriologic diagnosis of cellulitis in adults. J Clin Microbiol. 1988; 26(3):401-404.
20. Loffler CA, Macdougall C. Update on prevalence and treatment of methicillin-resistant Staphylococcus aureus infections. Expert Rev Anti Infect Ther. 2007;5(6):961-981.
21. Davis SL, McKinnon PS, Hall LM, et al. Daptomycin versus vancomycin for complicated skin and skin structure infections: clinical and economic outcomes. Pharmacotherapy. 2007;27(12):1611-1618.
22. Seaton RA. Daptomycin: rationale and role in the management of skin and soft tissue infections. J Antimicrob Chemother. 2008;62(Suppl 3):iii15-23.

Background

Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.¹ In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.²

HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:

• Diagnosing and treating underlying causes;
• Minimizing exacerbants;
• Optimizing management of comorbidities;
• Addressing psychosocial and environmental issues beyond the hospital; and
• Confronting end-of-life care.

In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.^3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.

Guideline Update

The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.^5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.⁸

The most notable updates from the 2009 guideline include (* = Class I and III indications):

• The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
• In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
• AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
• CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
• Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
• Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.

Analysis

Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.

A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.

Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.

HM Takeaways

HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.

Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.

References available at the-hospitalist.org.

Background

Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.¹ In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.²

HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:

• Diagnosing and treating underlying causes;
• Minimizing exacerbants;
• Optimizing management of comorbidities;
• Addressing psychosocial and environmental issues beyond the hospital; and
• Confronting end-of-life care.

In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.^3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.

Guideline Update

The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.^5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.⁸

The most notable updates from the 2009 guideline include (* = Class I and III indications):

• The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
• In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
• AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
• CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
• Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
• Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.

Analysis

Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.

A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.

Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.

HM Takeaways

HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.

Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.

References available at the-hospitalist.org.

Background

Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.¹ In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.²

HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:

• Diagnosing and treating underlying causes;
• Minimizing exacerbants;
• Optimizing management of comorbidities;
• Addressing psychosocial and environmental issues beyond the hospital; and
• Confronting end-of-life care.

In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.^3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.

Guideline Update

The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.^5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.⁸

The most notable updates from the 2009 guideline include (* = Class I and III indications):

• The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
• In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
• AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
• CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
• Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
• Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.

Analysis

Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.

A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.

Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.

HM Takeaways

HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.

Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.

References available at the-hospitalist.org.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.