Dr. Stephan

Before 2011, hospitalists had only Centers for Medicare & Medicaid Services’ (CMS) specialty-specific CPT distribution data, and no hospitalist-specific data, available when looking for benchmarks against which to compare their billing practices. Thanks to recent State of Hospital Medicine surveys, however, we now have hospitalist-specific data for the distribution of commonly used CPT codes. It’s interesting to analyze how 2011 data compares to 2012, and how the use of high-level codes varies by geographic region, employment model, compensation structure, and practice size.

In 2012, the use of the higher-level inpatient (IP) discharge code (99239) increased to 52% from 48% in 2011 among HM groups serving adults only, and the use of the highest-level IP subsequent code (99233) increased to 33% from 28% in the same comparison. This increase is in keeping with national trends. According to a May 2012 report by the Department of Health and Human Services’ Office of Inspector General, from 2001 to 2010, physicians’ billing shifted from lower-level to higher-level codes. For example, the billing of the lowest-level code (99231) decreased 16%, while the billing of the two higher-level codes (99232 and 99233) increased 6% and 9%, respectively.

Possible drivers of this change include:

• Expanded use of electronic health records (EHRs);
• Increased physician education about documentation requirements; and
• A sicker hospitalized patient population due to expanded outpatient care capabilities.

Although the proportion of high-level subsequent and discharge codes reported by SHM increased in 2012, the percent of highest-level IP admission codes (99223) actually decreased to 66% from 69%. There are many possible reasons for this. First, the elimination of consult codes by CMS in 2010 increased the overall use of admission codes but might have decreased the proportion of highest-level admission codes. Additionally, there may be an increased use of higher RVU-generating critical-care codes preferentially over billing of the highest-level admission codes. Third, there is the possibility that the extra documentation required for high-level admissions is a billing deterrent. Similarly, higher-level codes may be downcoded if documentation is lacking or incomplete.

Dr. Stephan

Comparatively, my health system, Allina Health, showed an increase in the use of highest-level codes for all three CPT codes analyzed.

With the increasing sophistication of EHRs and coding technology tools, it will be interesting to see the future impact on coding distribution as providers adapt to new documentation processes that support health information exchange across systems.

Comparing geographic regions, the West uses the highest proportion of high-level codes for admission, follow-up, and discharge, followed by the Midwest.

Interestingly, variation in billing by group size is only correlated directly to admission codes, but not to follow-up or discharge codes—with larger services tending to bill more of the highest-level admission codes.

Admission code use correlates directly with compensation structure; groups providing 100% of total compensation in the form of salary bill the lowest percentage of high-level admission codes. As compensation trends away from straight salaries, the percentage of high-level admission codes increases. The picture is less clear for high-level follow-up and discharge codes.

Comparing academic and nonacademic HM groups shows greater use of the highest- level admission, follow-up, and discharge codes for nonacademic HM groups. This is likely because academic hospitalists can only bill for their own time and not for time spent by medical residents.

Employment model (e.g. hospital system, private hospitalist-only groups, management companies, etc.) showed no categorical effect on CPT distribution.

Dr. Stephan is regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee.

Dr. Stephan

Before 2011, hospitalists had only Centers for Medicare & Medicaid Services’ (CMS) specialty-specific CPT distribution data, and no hospitalist-specific data, available when looking for benchmarks against which to compare their billing practices. Thanks to recent State of Hospital Medicine surveys, however, we now have hospitalist-specific data for the distribution of commonly used CPT codes. It’s interesting to analyze how 2011 data compares to 2012, and how the use of high-level codes varies by geographic region, employment model, compensation structure, and practice size.

In 2012, the use of the higher-level inpatient (IP) discharge code (99239) increased to 52% from 48% in 2011 among HM groups serving adults only, and the use of the highest-level IP subsequent code (99233) increased to 33% from 28% in the same comparison. This increase is in keeping with national trends. According to a May 2012 report by the Department of Health and Human Services’ Office of Inspector General, from 2001 to 2010, physicians’ billing shifted from lower-level to higher-level codes. For example, the billing of the lowest-level code (99231) decreased 16%, while the billing of the two higher-level codes (99232 and 99233) increased 6% and 9%, respectively.

Possible drivers of this change include:

• Expanded use of electronic health records (EHRs);
• Increased physician education about documentation requirements; and
• A sicker hospitalized patient population due to expanded outpatient care capabilities.

Although the proportion of high-level subsequent and discharge codes reported by SHM increased in 2012, the percent of highest-level IP admission codes (99223) actually decreased to 66% from 69%. There are many possible reasons for this. First, the elimination of consult codes by CMS in 2010 increased the overall use of admission codes but might have decreased the proportion of highest-level admission codes. Additionally, there may be an increased use of higher RVU-generating critical-care codes preferentially over billing of the highest-level admission codes. Third, there is the possibility that the extra documentation required for high-level admissions is a billing deterrent. Similarly, higher-level codes may be downcoded if documentation is lacking or incomplete.

Dr. Stephan

Comparatively, my health system, Allina Health, showed an increase in the use of highest-level codes for all three CPT codes analyzed.

With the increasing sophistication of EHRs and coding technology tools, it will be interesting to see the future impact on coding distribution as providers adapt to new documentation processes that support health information exchange across systems.

Comparing geographic regions, the West uses the highest proportion of high-level codes for admission, follow-up, and discharge, followed by the Midwest.

Interestingly, variation in billing by group size is only correlated directly to admission codes, but not to follow-up or discharge codes—with larger services tending to bill more of the highest-level admission codes.

Admission code use correlates directly with compensation structure; groups providing 100% of total compensation in the form of salary bill the lowest percentage of high-level admission codes. As compensation trends away from straight salaries, the percentage of high-level admission codes increases. The picture is less clear for high-level follow-up and discharge codes.

Comparing academic and nonacademic HM groups shows greater use of the highest- level admission, follow-up, and discharge codes for nonacademic HM groups. This is likely because academic hospitalists can only bill for their own time and not for time spent by medical residents.

Employment model (e.g. hospital system, private hospitalist-only groups, management companies, etc.) showed no categorical effect on CPT distribution.

Dr. Stephan is regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee.

Dr. Stephan

Before 2011, hospitalists had only Centers for Medicare & Medicaid Services’ (CMS) specialty-specific CPT distribution data, and no hospitalist-specific data, available when looking for benchmarks against which to compare their billing practices. Thanks to recent State of Hospital Medicine surveys, however, we now have hospitalist-specific data for the distribution of commonly used CPT codes. It’s interesting to analyze how 2011 data compares to 2012, and how the use of high-level codes varies by geographic region, employment model, compensation structure, and practice size.

In 2012, the use of the higher-level inpatient (IP) discharge code (99239) increased to 52% from 48% in 2011 among HM groups serving adults only, and the use of the highest-level IP subsequent code (99233) increased to 33% from 28% in the same comparison. This increase is in keeping with national trends. According to a May 2012 report by the Department of Health and Human Services’ Office of Inspector General, from 2001 to 2010, physicians’ billing shifted from lower-level to higher-level codes. For example, the billing of the lowest-level code (99231) decreased 16%, while the billing of the two higher-level codes (99232 and 99233) increased 6% and 9%, respectively.

Possible drivers of this change include:

• Expanded use of electronic health records (EHRs);
• Increased physician education about documentation requirements; and
• A sicker hospitalized patient population due to expanded outpatient care capabilities.

Although the proportion of high-level subsequent and discharge codes reported by SHM increased in 2012, the percent of highest-level IP admission codes (99223) actually decreased to 66% from 69%. There are many possible reasons for this. First, the elimination of consult codes by CMS in 2010 increased the overall use of admission codes but might have decreased the proportion of highest-level admission codes. Additionally, there may be an increased use of higher RVU-generating critical-care codes preferentially over billing of the highest-level admission codes. Third, there is the possibility that the extra documentation required for high-level admissions is a billing deterrent. Similarly, higher-level codes may be downcoded if documentation is lacking or incomplete.

Dr. Stephan

Comparatively, my health system, Allina Health, showed an increase in the use of highest-level codes for all three CPT codes analyzed.

With the increasing sophistication of EHRs and coding technology tools, it will be interesting to see the future impact on coding distribution as providers adapt to new documentation processes that support health information exchange across systems.

Comparing geographic regions, the West uses the highest proportion of high-level codes for admission, follow-up, and discharge, followed by the Midwest.

Interestingly, variation in billing by group size is only correlated directly to admission codes, but not to follow-up or discharge codes—with larger services tending to bill more of the highest-level admission codes.

Admission code use correlates directly with compensation structure; groups providing 100% of total compensation in the form of salary bill the lowest percentage of high-level admission codes. As compensation trends away from straight salaries, the percentage of high-level admission codes increases. The picture is less clear for high-level follow-up and discharge codes.

Comparing academic and nonacademic HM groups shows greater use of the highest- level admission, follow-up, and discharge codes for nonacademic HM groups. This is likely because academic hospitalists can only bill for their own time and not for time spent by medical residents.

Employment model (e.g. hospital system, private hospitalist-only groups, management companies, etc.) showed no categorical effect on CPT distribution.

Dr. Stephan is regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Case

A 25-year-old male with HIV/AIDS and a CD4 count of 65 cells/μL presents to the ED with intractable nausea and vomiting for one week. Laboratory evaluation revealed a white blood cell of 67,000 cells/mm3. An extended chemistry panel reveals creatinine 3.5 mg/dL, potassium 3.0 mmol/L, LDH 250 IU/L, and uric acid 5mg/dL. Calcium and phosphorus were both normal. The patient was admitted for further evaluation and management, and was later diagnosed with Burkitt’s lymphoma.

Overview

Tumor lysis syndrome (TLS) is an acute cell lysis of tumor cells with the release of cell content into circulation either spontaneously or in response to therapy, leading to hyperurecemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.^1-3

TLS is one of the most common oncology emergencies encountered by hospitalists caring for patients with hematologic malignancies. The incidence and severity of TLS depend on the cell burden, cell proliferation rate, potential for cell lysis or chemo sensitivity, baseline clinical characteristics, and preventive measures taken (see Table 1).^2,4

TLS is classified as laboratory or clinical. Laboratory TLS is described as the presence of two or more of the following serum abnormalities at the same time, present within three days before or seven days after the start of therapy.⁵

• Uric acid >8 mg/dL (475.8 micromole/L) or 25% increase;
• Potassium >6 mEq/L (6 mmol/L) or 25% increase;
• Phosphorus >6.5 mg/dL (2.1 mmol/L) for children or >4.5 mg/dl (1.45 mmol/L) for adults or 25% increase; and
• Calcium >7 mg/dL (1.75 mmol/L) or 25% increase.

Clinical TLS is defined as laboratory TLS in association with increased creatinine levels, seizures, cardiac arrhythmias, or death (see Table 2).⁵

Pathogenesis

Tumor cell lysis releases DNA, cytokines, phosphate, and potassium. DNA is metabolized into adenosine and guanosine, which are then converted into xanthines. Xanthines are oxidized by xanthine oxidase into uric acid, which is then excreted through the kidneys.

TLS develops when the accumulation of xanthine, uric acid, potassium, and phosphorus exceeds the kidney’s capacity to excrete them. Cytokines cause hypotension, inflammation, and kidney injury, and worsen the kidney’s excretory capacity. Damage to the kidneys also occurs by renal precipitation of uric acid, xanthine, and calcium phosphate.⁴

Phosphorus concentrations in tumor cells are four times higher than in normal cells. When the calcium phosphorus product exceeds 60 mg2/dL2, there is an increased risk of calcium phosphate precipitation in the kidney tubules, which could lead to kidney failure. Accumulation of calcium phosphate product may also be cardiotoxic and can lead to cardiac arrhythmias. In addition, hyperphosphatemia can cause secondary hypocalcemia, which may lead to parasthesias, tetany, and cardiac arrhythmias.^2,4

TLS is most common in tumors with high proliferative rates and high tumor burden, such as acute lymphoblastic leukemia and Burkitt’s lymphoma, but it can occur with other hematologic malignancies, such as T-cell precursor acute lymphocytic leukemia (ALL), B-cell precursor ALL, acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), anaplastic large cell lymphoma, and plasma cell disorders (e.g. multiple myeloma and plasmacytoma).^6,7 TLS has also been reported with the treatment of solid organ nonhematologic tumors (see Table 3).

In hematologic tumors, TLS frequently is associated with cytotoxic chemotherapy, and less frequently with glucocorticoid treatment, monoclonal antibodies (eg, rituximab, bortezomab, imatinib), and radiation therapy.^25-29

Patient factors, such as baseline kidney disease or lack of prophylactic/preventive measures for TLS, also increase the risk.4 TLS, however, can develop in patients classified as low risk (see Table 1.

click for large version

click for large version

TLS Prevention

Intravenous fluids. Every patient at intermediate or high risk of TLS should receive intravenous fluids (IVF) prior to cancer treatment; those at low risk may receive IVF based on the provider’s clinical judgment.³⁰ The purpose of administering IVF is to generate high urine output to reduce the risk of precipitation of uric acid in the renal tubules.³⁰ Both adults and children should receive approximately 2 to 3 L/m2 per day of IVF,30 and urine output should be maintained at 2 ml/kg/hr (or 4 to 6 ml/kg/hr for children <10kg).30 IVF should be cautiously administered in patients with renal insufficiency or heart failure, and diuretics may be used to maintain goal urine output. Recommended initial fluids are D51/4 normal saline, or normal saline for patients who are dehydrated or hyponatremic.³⁰

Allopurinol. Allopurinol is usually also administered to patients at risk for developing TLS.³⁰ Allopurinol inhibits the metabolism of hypoxanthine and xanthine to uric acid, which decreases the accumulation of uric acid in the renal tubules, thus preventing obstructive renal disease from precipitation of uric acid.⁴ The recommended dose of allopurinol is 100 mg/m2 every eight hours, and should not exceed 800 mg per day in adults. It should be started one to two days prior to induction chemotherapy and continued for three to seven days after the treatment and until uric acid levels and other electrolyte levels have returned to normal. The dose is adjusted to 50 mg/m2 every eight hours in patients with kidney failure.³⁰

In some cases, allopurinol can lead to increased levels of xanthine crystals in the renal tubules, leading to acute kidney injury. Also, allopurinol does not have any effect on uric acid that has already been formed, so patients with elevated uric acid levels prior to the initiation of cancer therapy will not have any reduction in the levels of uric acid. Allopurinol reduces the degradation of other purines, so it can cause toxicity in patients on azathioprine and 6-mercaptopurine if the doses of these medications are not adjusted.

Rasburicase. Rasburicase is a recombinant urate oxidase, derived from aspergillus favus, which catalyzes the breakdown of uric acid to allantoin, which is a water-soluble product. Rasburicase is recommended as a first-line treatment for patients at high risk for clinical TLS.³⁰ Rasburicase has an earlier onset than allopurinol and rapidly decreases serum levels of uric acid within four hours of administration.^30,31 The recommended dose is 0.10 to 0.20 mg/kg once a day for five days in adults.³⁰

A Phase III trial compared the efficiency and safety of rasburicase to rasburicase with allopurinol or allopurinol alone.³² A significantly higher normalization of uric acid was found in patients on rasburicase compared to allopurinol alone. The incidence of laboratory TLS was also significantly lower with rasburicase alone compared to allopurinol alone, and was even lower with allopurinol plus rasburicase. The incidence of acute kidney injury was the same with rasburicase alone or allopurinol alone but was higher with rasburicase plus allopurinol.

Serum uric acid, phosphorus, potassium, and calcium need to be monitored every four hours for 24 hours after the completion of chemotherapy in patients on rasburicase.⁴ The sample of blood drawn to check the uric acid levels has to be placed on ice and processed within four hours in order to avoid falsely lower levels of uric acid due to the conversion of uric acid to allantoin. Rasburicase is contraindicated in patients with G6PD deficiency and pregnant women, because one of the byproducts of uric acid breakdown is hydrogen peroxide, which can cause severe hemolysis and the formation of methemoglobin in these patients.³⁰

Rasburicase has been approved for use in both children and adults, but there is more evidence for the use in children. Rasburicase has a black-box label for patients with anaphylaxis, methemoglobinemia, hemolysis, and hemoglobinuria, and there is a recommendation to check G6PD deficiency before use in high-risk patients.³⁰

TLS Treatment

Alkalinization. Alkalinization of urine is controversial in the management of TLS. Urine alkalinization increases uric acid solubility but causes hyperphosphatemia and decreases calcium phosphate solubility, which can then deposit in the kidney once cancer treatment starts. Of note, hyperphosphatemia is much more difficult to correct than high levels of uric acid, and there are no clinical trials proving the superiority of urine alkalinization over normal saline.

Normalization of electrolytes. Electrolyte abnormalities should be corrected to avoid arrhythmias and seizures. Phosphorus levels >6.5 mg/dl (2.1 mmol/L) should be managed by restricting phosphorus intake, and by the use of phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum, or aluminum hydroxide). Aluminum hydroxide should be avoided in patients with renal insufficiency. In severe cases of hyperphosphatemia, dialysis should be considered.

Symptomatic hypocalcemia should be treated with calcium gluconate if changes are present on the electrocardiography (ECG). Hypocalcemia in the presence of hyperphosphatemia should be treated only in patients with tetany or cardiac arrhythmias; otherwise, hypocalcemia should not be treated until hyperphosphatemia has been corrected.

In cases of hyperkalemia, patients should be placed on a cardiac monitor and stabilized with calcium gluconate; kayexalate should be administered to reduce total body potassium. Other interventions, such as intravenous insulin given with dextrose, sodium bicarbonate, and albuterol, have a temporary effect on hyperkalemia and can be used as adjunct treatments in patients with severe hyperkalemia (>7). Hemodialysis should be strongly considered in severe cases of hyperkalemia, particularly in patients with persistently elevated potassium levels despite other treatments.

Back to the Case

Our patient was started on IVFs with close monitoring of his urine output. He was considered intermediate risk for developing TLS. Allopurinol, renally dosed, was administered for two days prior to initiating treatment with rituximab plus chemotherapy. His chemistry panel was monitored daily and he did not develop any form of TLS.

Bottom Line

TLS is a common oncology emergency in patients with hematologic malignancies. Preventative measures include starting IVF prior to cancer treatment, and administering allopurinol and/or rasburicase to patients at risk of developing TLS. Treatment should include normalizing electrolytes to avoid arrhythmias and seizures.

Dr. Akwe is assistant professor of medicine at the Emory University School of Medicine and a clinical instructor of medicine at the Morehouse School of Medicine, both in Atlanta. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory. Both work as hospitalists at the Atlanta VA Medical Center.

References

1. Abu-Alfa AK, Younes A. Tumor lysis syndrome and acute kidney injury: evaluation, prevention, and management. Am J Kidney Dis. 2010;55:Suppl 3:S1-S13.
2. Cairo MS, Coiffier B, Reiter A, Younes A. Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus. Br J Haematol. 2010;149:578-586.
3. Gertz MA. Managing tumor lysis syndrome in 2010. Leuk Lymphoma. 2010;51:179-180.
4. Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364:1844.
5. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127:3.
6. Wössmann W, Schrappe M, Meyer U, et al. Incidence of tumor lysis syndrome in children with advanced stage Burkitt’s lymphoma/leukemia before and after introduction of prophylactic use of urate oxidase. Ann Hematol. 2003;82:160.
7. Hussain K, Mazza JJ, Clouse LH. Tumor lysis syndrome (TLS) following fludarabine therapy Gemici C. Tumor lysis syndrome in solid tumors. J Clin Oncol. 2009;27:2738-2739
8. Rostom AY, El-Hussainy G, Kandil A, Allam A. Tumor lysis syndrome following hemi-body irradiation for metastatic breast cancer. Ann Oncol. 2000;11:1349.
9. Drakos P, Bar-Ziv J, Catane R. Tumor lysis syndrome in nonhematologic malignancies. Report of a case and review of the literature. Am J Clin Oncol. 1994;17:502.
10. Baeksgaard L, Sørensen JB. Acute tumor lysis syndrome in solid tumors—a case report and review of the literature. Cancer Chemother Pharmacol. 2003;51:187.
11. Kalemkerian GP, Darwish B, Varterasian ML. Tumor lysis syndrome in small cell carcinoma and other solid tumors. Am J Med. 1997;103:363.
12. Noh GY, Choe DH, Kim CH, Lee JC. Fatal tumor lysis syndrome during radiotherapy for non-small-cell lung cancer. J Clin Oncol. 2008;26:6005-6006.
13. Pentheroudakis G, O’Neill VJ, Vasey P, Kaye SB. Spontaneous acute tumour lysis syndrome in patients with metastatic germ cell tumours. Report of two cases. Support Care Cancer. 2001;9:554.
14. Joshita S, Yoshizawa K, Sano K, et al., A patient with advanced hepatocellular carcinoma treated with sorafenib tosylate showed massive tumor lysis with avoidance of tumor lysis syndrome. Intern Med. 2010;49:991-994.
15. Huang WS, Yang CH. Sorafenib-induced tumor lysis syndrome in an advanced hepatocellular carcinoma patient. World J Gastroenterol. 2009;15:4464-4466.
16. Bilgrami SF, Fallon BG. Tumor lysis syndrome after combination chemotherapy for ovarian cancer. Med Pediatr Oncol. 1993;21:521.
17. Chan JK, Lin SS, McMeekin DS, Berman ML. Patients with malignancy requiring urgent therapy: CASE 3. Tumor lysis syndrome associated with chemotherapy in ovarian cancer. J Clin Oncol. 2005;23:6794.
18. Godoy H, Kesterson JP, Lele S. Tumor lysis syndrome associated with carboplatin and paclitaxel in a woman with recurrent endometrial cancer. Int J Gynaecol Obstet. 2010;109:254.
19. Shamseddine AI, Khalil AM, Wehbeh MH. Acute tumor lysis syndrome with squamous cell carcinoma of the vulva. Gynecol Oncol 1993;51:258
20. Pinder EM, Atwal GS, Ayantunde AA, et al. Tumour lysis syndrome occurring in a patient with metastatic gastrointestinal stromal tumour treated with Glivec (imatinib mesylate, Gleevec, STI571). Sarcoma. 2007;2007:82012.
21. Krishnan G, D’Silva K, Al-Janadi A. Cetuximab-related tumor lysis syndrome in metastatic colon carcinoma. J Clin Oncol. 2008;26:2406-2408.
22. Oztop I, Demirkan B, Yaren A, et al. Rapid tumor lysis syndrome in a patient with metastatic colon cancer as a complication of treatment with 5-fluorouracil/leucoverin and irinotecan. Tumori. 2004;90:514.
23. Lin CJ, Lim KH, Cheng YC, et al. Tumor lysis syndrome after treatment with gemcitabine for metastatic transitional cell carcinoma. Med Oncol. 2007;24:455.
24. Malik IA, Abubakar S, Alam F, Khan A. Dexamethasone-induced tumor lysis syndrome in high-grade non-Hodgkin’s lymphoma. South Med J. 1994;87:409.
25. Jabr FI. Acute tumor lysis syndrome induced by rituximab in diffuse large B-cell lymphoma. Int J Hematol. 2005;82:312.
26. Sezer O, Vesole DH, Singhal S, et al. Bortezomib-induced tumor lysis syndrome in multiple myeloma. Clin Lymphoma Myeloma. 2006;7:233.
27. Jensen M, Winkler U, Manzke O, et al. Rapid tumor lysis in a patient with B-cell chronic lymphocytic leukemia and lymphocytosis treated with an anti-CD20 monoclonal antibody (IDEC-C2B8, rituximab). Ann Hematol. 1998;77:89.
28. Linck D, Basara N, Tran V, et al. Peracute onset of severe tumor lysis syndrome immediately after 4 Gy fractionated TBI as part of reduced intensity preparative regimen in a patient with T-ALL with high tumor burden. Bone Marrow Transplant. 2003;31:935.
29. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008;26(16):2767-2778. [Erratum, J Clin Oncol. 2010;28:708.]
30. Cheuk DK, Chiang AK, Chan GC, Ha SY. Urate oxidase for the prevention and treatment of tumor lysis syndrome in children with cancer. Cochrane Database Syst Rev. 2010;(6):CD006945.
31. Cortes J, Moore JO, Maziarz RT, et al. Control of plasma uric acid in adults at risk for tumor Lysis syndrome: efficacy and safety of rasburicase alone and rasburicase followed by allopurinol compared with allopurinol alone—results of a multicenter phase III study. J Clin Oncol. 2010;28:4207.

Case

A 25-year-old male with HIV/AIDS and a CD4 count of 65 cells/μL presents to the ED with intractable nausea and vomiting for one week. Laboratory evaluation revealed a white blood cell of 67,000 cells/mm3. An extended chemistry panel reveals creatinine 3.5 mg/dL, potassium 3.0 mmol/L, LDH 250 IU/L, and uric acid 5mg/dL. Calcium and phosphorus were both normal. The patient was admitted for further evaluation and management, and was later diagnosed with Burkitt’s lymphoma.

Overview

Tumor lysis syndrome (TLS) is an acute cell lysis of tumor cells with the release of cell content into circulation either spontaneously or in response to therapy, leading to hyperurecemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.^1-3

TLS is one of the most common oncology emergencies encountered by hospitalists caring for patients with hematologic malignancies. The incidence and severity of TLS depend on the cell burden, cell proliferation rate, potential for cell lysis or chemo sensitivity, baseline clinical characteristics, and preventive measures taken (see Table 1).^2,4

TLS is classified as laboratory or clinical. Laboratory TLS is described as the presence of two or more of the following serum abnormalities at the same time, present within three days before or seven days after the start of therapy.⁵

• Uric acid >8 mg/dL (475.8 micromole/L) or 25% increase;
• Potassium >6 mEq/L (6 mmol/L) or 25% increase;
• Phosphorus >6.5 mg/dL (2.1 mmol/L) for children or >4.5 mg/dl (1.45 mmol/L) for adults or 25% increase; and
• Calcium >7 mg/dL (1.75 mmol/L) or 25% increase.

Clinical TLS is defined as laboratory TLS in association with increased creatinine levels, seizures, cardiac arrhythmias, or death (see Table 2).⁵

Pathogenesis

Tumor cell lysis releases DNA, cytokines, phosphate, and potassium. DNA is metabolized into adenosine and guanosine, which are then converted into xanthines. Xanthines are oxidized by xanthine oxidase into uric acid, which is then excreted through the kidneys.

TLS develops when the accumulation of xanthine, uric acid, potassium, and phosphorus exceeds the kidney’s capacity to excrete them. Cytokines cause hypotension, inflammation, and kidney injury, and worsen the kidney’s excretory capacity. Damage to the kidneys also occurs by renal precipitation of uric acid, xanthine, and calcium phosphate.⁴

Phosphorus concentrations in tumor cells are four times higher than in normal cells. When the calcium phosphorus product exceeds 60 mg2/dL2, there is an increased risk of calcium phosphate precipitation in the kidney tubules, which could lead to kidney failure. Accumulation of calcium phosphate product may also be cardiotoxic and can lead to cardiac arrhythmias. In addition, hyperphosphatemia can cause secondary hypocalcemia, which may lead to parasthesias, tetany, and cardiac arrhythmias.^2,4

TLS is most common in tumors with high proliferative rates and high tumor burden, such as acute lymphoblastic leukemia and Burkitt’s lymphoma, but it can occur with other hematologic malignancies, such as T-cell precursor acute lymphocytic leukemia (ALL), B-cell precursor ALL, acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), anaplastic large cell lymphoma, and plasma cell disorders (e.g. multiple myeloma and plasmacytoma).^6,7 TLS has also been reported with the treatment of solid organ nonhematologic tumors (see Table 3).

In hematologic tumors, TLS frequently is associated with cytotoxic chemotherapy, and less frequently with glucocorticoid treatment, monoclonal antibodies (eg, rituximab, bortezomab, imatinib), and radiation therapy.^25-29

Patient factors, such as baseline kidney disease or lack of prophylactic/preventive measures for TLS, also increase the risk.4 TLS, however, can develop in patients classified as low risk (see Table 1.

click for large version

click for large version

TLS Prevention

Intravenous fluids. Every patient at intermediate or high risk of TLS should receive intravenous fluids (IVF) prior to cancer treatment; those at low risk may receive IVF based on the provider’s clinical judgment.³⁰ The purpose of administering IVF is to generate high urine output to reduce the risk of precipitation of uric acid in the renal tubules.³⁰ Both adults and children should receive approximately 2 to 3 L/m2 per day of IVF,30 and urine output should be maintained at 2 ml/kg/hr (or 4 to 6 ml/kg/hr for children <10kg).30 IVF should be cautiously administered in patients with renal insufficiency or heart failure, and diuretics may be used to maintain goal urine output. Recommended initial fluids are D51/4 normal saline, or normal saline for patients who are dehydrated or hyponatremic.³⁰

Allopurinol. Allopurinol is usually also administered to patients at risk for developing TLS.³⁰ Allopurinol inhibits the metabolism of hypoxanthine and xanthine to uric acid, which decreases the accumulation of uric acid in the renal tubules, thus preventing obstructive renal disease from precipitation of uric acid.⁴ The recommended dose of allopurinol is 100 mg/m2 every eight hours, and should not exceed 800 mg per day in adults. It should be started one to two days prior to induction chemotherapy and continued for three to seven days after the treatment and until uric acid levels and other electrolyte levels have returned to normal. The dose is adjusted to 50 mg/m2 every eight hours in patients with kidney failure.³⁰

In some cases, allopurinol can lead to increased levels of xanthine crystals in the renal tubules, leading to acute kidney injury. Also, allopurinol does not have any effect on uric acid that has already been formed, so patients with elevated uric acid levels prior to the initiation of cancer therapy will not have any reduction in the levels of uric acid. Allopurinol reduces the degradation of other purines, so it can cause toxicity in patients on azathioprine and 6-mercaptopurine if the doses of these medications are not adjusted.

Rasburicase. Rasburicase is a recombinant urate oxidase, derived from aspergillus favus, which catalyzes the breakdown of uric acid to allantoin, which is a water-soluble product. Rasburicase is recommended as a first-line treatment for patients at high risk for clinical TLS.³⁰ Rasburicase has an earlier onset than allopurinol and rapidly decreases serum levels of uric acid within four hours of administration.^30,31 The recommended dose is 0.10 to 0.20 mg/kg once a day for five days in adults.³⁰

A Phase III trial compared the efficiency and safety of rasburicase to rasburicase with allopurinol or allopurinol alone.³² A significantly higher normalization of uric acid was found in patients on rasburicase compared to allopurinol alone. The incidence of laboratory TLS was also significantly lower with rasburicase alone compared to allopurinol alone, and was even lower with allopurinol plus rasburicase. The incidence of acute kidney injury was the same with rasburicase alone or allopurinol alone but was higher with rasburicase plus allopurinol.

Serum uric acid, phosphorus, potassium, and calcium need to be monitored every four hours for 24 hours after the completion of chemotherapy in patients on rasburicase.⁴ The sample of blood drawn to check the uric acid levels has to be placed on ice and processed within four hours in order to avoid falsely lower levels of uric acid due to the conversion of uric acid to allantoin. Rasburicase is contraindicated in patients with G6PD deficiency and pregnant women, because one of the byproducts of uric acid breakdown is hydrogen peroxide, which can cause severe hemolysis and the formation of methemoglobin in these patients.³⁰

Rasburicase has been approved for use in both children and adults, but there is more evidence for the use in children. Rasburicase has a black-box label for patients with anaphylaxis, methemoglobinemia, hemolysis, and hemoglobinuria, and there is a recommendation to check G6PD deficiency before use in high-risk patients.³⁰

TLS Treatment

Alkalinization. Alkalinization of urine is controversial in the management of TLS. Urine alkalinization increases uric acid solubility but causes hyperphosphatemia and decreases calcium phosphate solubility, which can then deposit in the kidney once cancer treatment starts. Of note, hyperphosphatemia is much more difficult to correct than high levels of uric acid, and there are no clinical trials proving the superiority of urine alkalinization over normal saline.

Normalization of electrolytes. Electrolyte abnormalities should be corrected to avoid arrhythmias and seizures. Phosphorus levels >6.5 mg/dl (2.1 mmol/L) should be managed by restricting phosphorus intake, and by the use of phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum, or aluminum hydroxide). Aluminum hydroxide should be avoided in patients with renal insufficiency. In severe cases of hyperphosphatemia, dialysis should be considered.

Symptomatic hypocalcemia should be treated with calcium gluconate if changes are present on the electrocardiography (ECG). Hypocalcemia in the presence of hyperphosphatemia should be treated only in patients with tetany or cardiac arrhythmias; otherwise, hypocalcemia should not be treated until hyperphosphatemia has been corrected.

In cases of hyperkalemia, patients should be placed on a cardiac monitor and stabilized with calcium gluconate; kayexalate should be administered to reduce total body potassium. Other interventions, such as intravenous insulin given with dextrose, sodium bicarbonate, and albuterol, have a temporary effect on hyperkalemia and can be used as adjunct treatments in patients with severe hyperkalemia (>7). Hemodialysis should be strongly considered in severe cases of hyperkalemia, particularly in patients with persistently elevated potassium levels despite other treatments.

Back to the Case

Our patient was started on IVFs with close monitoring of his urine output. He was considered intermediate risk for developing TLS. Allopurinol, renally dosed, was administered for two days prior to initiating treatment with rituximab plus chemotherapy. His chemistry panel was monitored daily and he did not develop any form of TLS.

Bottom Line

TLS is a common oncology emergency in patients with hematologic malignancies. Preventative measures include starting IVF prior to cancer treatment, and administering allopurinol and/or rasburicase to patients at risk of developing TLS. Treatment should include normalizing electrolytes to avoid arrhythmias and seizures.

Dr. Akwe is assistant professor of medicine at the Emory University School of Medicine and a clinical instructor of medicine at the Morehouse School of Medicine, both in Atlanta. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory. Both work as hospitalists at the Atlanta VA Medical Center.

References

1. Abu-Alfa AK, Younes A. Tumor lysis syndrome and acute kidney injury: evaluation, prevention, and management. Am J Kidney Dis. 2010;55:Suppl 3:S1-S13.
2. Cairo MS, Coiffier B, Reiter A, Younes A. Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus. Br J Haematol. 2010;149:578-586.
3. Gertz MA. Managing tumor lysis syndrome in 2010. Leuk Lymphoma. 2010;51:179-180.
4. Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364:1844.
5. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127:3.
6. Wössmann W, Schrappe M, Meyer U, et al. Incidence of tumor lysis syndrome in children with advanced stage Burkitt’s lymphoma/leukemia before and after introduction of prophylactic use of urate oxidase. Ann Hematol. 2003;82:160.
7. Hussain K, Mazza JJ, Clouse LH. Tumor lysis syndrome (TLS) following fludarabine therapy Gemici C. Tumor lysis syndrome in solid tumors. J Clin Oncol. 2009;27:2738-2739
8. Rostom AY, El-Hussainy G, Kandil A, Allam A. Tumor lysis syndrome following hemi-body irradiation for metastatic breast cancer. Ann Oncol. 2000;11:1349.
9. Drakos P, Bar-Ziv J, Catane R. Tumor lysis syndrome in nonhematologic malignancies. Report of a case and review of the literature. Am J Clin Oncol. 1994;17:502.
10. Baeksgaard L, Sørensen JB. Acute tumor lysis syndrome in solid tumors—a case report and review of the literature. Cancer Chemother Pharmacol. 2003;51:187.
11. Kalemkerian GP, Darwish B, Varterasian ML. Tumor lysis syndrome in small cell carcinoma and other solid tumors. Am J Med. 1997;103:363.
12. Noh GY, Choe DH, Kim CH, Lee JC. Fatal tumor lysis syndrome during radiotherapy for non-small-cell lung cancer. J Clin Oncol. 2008;26:6005-6006.
13. Pentheroudakis G, O’Neill VJ, Vasey P, Kaye SB. Spontaneous acute tumour lysis syndrome in patients with metastatic germ cell tumours. Report of two cases. Support Care Cancer. 2001;9:554.
14. Joshita S, Yoshizawa K, Sano K, et al., A patient with advanced hepatocellular carcinoma treated with sorafenib tosylate showed massive tumor lysis with avoidance of tumor lysis syndrome. Intern Med. 2010;49:991-994.
15. Huang WS, Yang CH. Sorafenib-induced tumor lysis syndrome in an advanced hepatocellular carcinoma patient. World J Gastroenterol. 2009;15:4464-4466.
16. Bilgrami SF, Fallon BG. Tumor lysis syndrome after combination chemotherapy for ovarian cancer. Med Pediatr Oncol. 1993;21:521.
17. Chan JK, Lin SS, McMeekin DS, Berman ML. Patients with malignancy requiring urgent therapy: CASE 3. Tumor lysis syndrome associated with chemotherapy in ovarian cancer. J Clin Oncol. 2005;23:6794.
18. Godoy H, Kesterson JP, Lele S. Tumor lysis syndrome associated with carboplatin and paclitaxel in a woman with recurrent endometrial cancer. Int J Gynaecol Obstet. 2010;109:254.
19. Shamseddine AI, Khalil AM, Wehbeh MH. Acute tumor lysis syndrome with squamous cell carcinoma of the vulva. Gynecol Oncol 1993;51:258
20. Pinder EM, Atwal GS, Ayantunde AA, et al. Tumour lysis syndrome occurring in a patient with metastatic gastrointestinal stromal tumour treated with Glivec (imatinib mesylate, Gleevec, STI571). Sarcoma. 2007;2007:82012.
21. Krishnan G, D’Silva K, Al-Janadi A. Cetuximab-related tumor lysis syndrome in metastatic colon carcinoma. J Clin Oncol. 2008;26:2406-2408.
22. Oztop I, Demirkan B, Yaren A, et al. Rapid tumor lysis syndrome in a patient with metastatic colon cancer as a complication of treatment with 5-fluorouracil/leucoverin and irinotecan. Tumori. 2004;90:514.
23. Lin CJ, Lim KH, Cheng YC, et al. Tumor lysis syndrome after treatment with gemcitabine for metastatic transitional cell carcinoma. Med Oncol. 2007;24:455.
24. Malik IA, Abubakar S, Alam F, Khan A. Dexamethasone-induced tumor lysis syndrome in high-grade non-Hodgkin’s lymphoma. South Med J. 1994;87:409.
25. Jabr FI. Acute tumor lysis syndrome induced by rituximab in diffuse large B-cell lymphoma. Int J Hematol. 2005;82:312.
26. Sezer O, Vesole DH, Singhal S, et al. Bortezomib-induced tumor lysis syndrome in multiple myeloma. Clin Lymphoma Myeloma. 2006;7:233.
27. Jensen M, Winkler U, Manzke O, et al. Rapid tumor lysis in a patient with B-cell chronic lymphocytic leukemia and lymphocytosis treated with an anti-CD20 monoclonal antibody (IDEC-C2B8, rituximab). Ann Hematol. 1998;77:89.
28. Linck D, Basara N, Tran V, et al. Peracute onset of severe tumor lysis syndrome immediately after 4 Gy fractionated TBI as part of reduced intensity preparative regimen in a patient with T-ALL with high tumor burden. Bone Marrow Transplant. 2003;31:935.
29. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008;26(16):2767-2778. [Erratum, J Clin Oncol. 2010;28:708.]
30. Cheuk DK, Chiang AK, Chan GC, Ha SY. Urate oxidase for the prevention and treatment of tumor lysis syndrome in children with cancer. Cochrane Database Syst Rev. 2010;(6):CD006945.
31. Cortes J, Moore JO, Maziarz RT, et al. Control of plasma uric acid in adults at risk for tumor Lysis syndrome: efficacy and safety of rasburicase alone and rasburicase followed by allopurinol compared with allopurinol alone—results of a multicenter phase III study. J Clin Oncol. 2010;28:4207.

Case

A 25-year-old male with HIV/AIDS and a CD4 count of 65 cells/μL presents to the ED with intractable nausea and vomiting for one week. Laboratory evaluation revealed a white blood cell of 67,000 cells/mm3. An extended chemistry panel reveals creatinine 3.5 mg/dL, potassium 3.0 mmol/L, LDH 250 IU/L, and uric acid 5mg/dL. Calcium and phosphorus were both normal. The patient was admitted for further evaluation and management, and was later diagnosed with Burkitt’s lymphoma.

Overview

Tumor lysis syndrome (TLS) is an acute cell lysis of tumor cells with the release of cell content into circulation either spontaneously or in response to therapy, leading to hyperurecemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.^1-3

TLS is one of the most common oncology emergencies encountered by hospitalists caring for patients with hematologic malignancies. The incidence and severity of TLS depend on the cell burden, cell proliferation rate, potential for cell lysis or chemo sensitivity, baseline clinical characteristics, and preventive measures taken (see Table 1).^2,4

TLS is classified as laboratory or clinical. Laboratory TLS is described as the presence of two or more of the following serum abnormalities at the same time, present within three days before or seven days after the start of therapy.⁵

• Uric acid >8 mg/dL (475.8 micromole/L) or 25% increase;
• Potassium >6 mEq/L (6 mmol/L) or 25% increase;
• Phosphorus >6.5 mg/dL (2.1 mmol/L) for children or >4.5 mg/dl (1.45 mmol/L) for adults or 25% increase; and
• Calcium >7 mg/dL (1.75 mmol/L) or 25% increase.

Clinical TLS is defined as laboratory TLS in association with increased creatinine levels, seizures, cardiac arrhythmias, or death (see Table 2).⁵

Pathogenesis

Tumor cell lysis releases DNA, cytokines, phosphate, and potassium. DNA is metabolized into adenosine and guanosine, which are then converted into xanthines. Xanthines are oxidized by xanthine oxidase into uric acid, which is then excreted through the kidneys.

TLS develops when the accumulation of xanthine, uric acid, potassium, and phosphorus exceeds the kidney’s capacity to excrete them. Cytokines cause hypotension, inflammation, and kidney injury, and worsen the kidney’s excretory capacity. Damage to the kidneys also occurs by renal precipitation of uric acid, xanthine, and calcium phosphate.⁴

Phosphorus concentrations in tumor cells are four times higher than in normal cells. When the calcium phosphorus product exceeds 60 mg2/dL2, there is an increased risk of calcium phosphate precipitation in the kidney tubules, which could lead to kidney failure. Accumulation of calcium phosphate product may also be cardiotoxic and can lead to cardiac arrhythmias. In addition, hyperphosphatemia can cause secondary hypocalcemia, which may lead to parasthesias, tetany, and cardiac arrhythmias.^2,4

TLS is most common in tumors with high proliferative rates and high tumor burden, such as acute lymphoblastic leukemia and Burkitt’s lymphoma, but it can occur with other hematologic malignancies, such as T-cell precursor acute lymphocytic leukemia (ALL), B-cell precursor ALL, acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), anaplastic large cell lymphoma, and plasma cell disorders (e.g. multiple myeloma and plasmacytoma).^6,7 TLS has also been reported with the treatment of solid organ nonhematologic tumors (see Table 3).

In hematologic tumors, TLS frequently is associated with cytotoxic chemotherapy, and less frequently with glucocorticoid treatment, monoclonal antibodies (eg, rituximab, bortezomab, imatinib), and radiation therapy.^25-29

Patient factors, such as baseline kidney disease or lack of prophylactic/preventive measures for TLS, also increase the risk.4 TLS, however, can develop in patients classified as low risk (see Table 1.

click for large version

click for large version

TLS Prevention

Intravenous fluids. Every patient at intermediate or high risk of TLS should receive intravenous fluids (IVF) prior to cancer treatment; those at low risk may receive IVF based on the provider’s clinical judgment.³⁰ The purpose of administering IVF is to generate high urine output to reduce the risk of precipitation of uric acid in the renal tubules.³⁰ Both adults and children should receive approximately 2 to 3 L/m2 per day of IVF,30 and urine output should be maintained at 2 ml/kg/hr (or 4 to 6 ml/kg/hr for children <10kg).30 IVF should be cautiously administered in patients with renal insufficiency or heart failure, and diuretics may be used to maintain goal urine output. Recommended initial fluids are D51/4 normal saline, or normal saline for patients who are dehydrated or hyponatremic.³⁰

Allopurinol. Allopurinol is usually also administered to patients at risk for developing TLS.³⁰ Allopurinol inhibits the metabolism of hypoxanthine and xanthine to uric acid, which decreases the accumulation of uric acid in the renal tubules, thus preventing obstructive renal disease from precipitation of uric acid.⁴ The recommended dose of allopurinol is 100 mg/m2 every eight hours, and should not exceed 800 mg per day in adults. It should be started one to two days prior to induction chemotherapy and continued for three to seven days after the treatment and until uric acid levels and other electrolyte levels have returned to normal. The dose is adjusted to 50 mg/m2 every eight hours in patients with kidney failure.³⁰

In some cases, allopurinol can lead to increased levels of xanthine crystals in the renal tubules, leading to acute kidney injury. Also, allopurinol does not have any effect on uric acid that has already been formed, so patients with elevated uric acid levels prior to the initiation of cancer therapy will not have any reduction in the levels of uric acid. Allopurinol reduces the degradation of other purines, so it can cause toxicity in patients on azathioprine and 6-mercaptopurine if the doses of these medications are not adjusted.

Rasburicase. Rasburicase is a recombinant urate oxidase, derived from aspergillus favus, which catalyzes the breakdown of uric acid to allantoin, which is a water-soluble product. Rasburicase is recommended as a first-line treatment for patients at high risk for clinical TLS.³⁰ Rasburicase has an earlier onset than allopurinol and rapidly decreases serum levels of uric acid within four hours of administration.^30,31 The recommended dose is 0.10 to 0.20 mg/kg once a day for five days in adults.³⁰

A Phase III trial compared the efficiency and safety of rasburicase to rasburicase with allopurinol or allopurinol alone.³² A significantly higher normalization of uric acid was found in patients on rasburicase compared to allopurinol alone. The incidence of laboratory TLS was also significantly lower with rasburicase alone compared to allopurinol alone, and was even lower with allopurinol plus rasburicase. The incidence of acute kidney injury was the same with rasburicase alone or allopurinol alone but was higher with rasburicase plus allopurinol.

Serum uric acid, phosphorus, potassium, and calcium need to be monitored every four hours for 24 hours after the completion of chemotherapy in patients on rasburicase.⁴ The sample of blood drawn to check the uric acid levels has to be placed on ice and processed within four hours in order to avoid falsely lower levels of uric acid due to the conversion of uric acid to allantoin. Rasburicase is contraindicated in patients with G6PD deficiency and pregnant women, because one of the byproducts of uric acid breakdown is hydrogen peroxide, which can cause severe hemolysis and the formation of methemoglobin in these patients.³⁰

Rasburicase has been approved for use in both children and adults, but there is more evidence for the use in children. Rasburicase has a black-box label for patients with anaphylaxis, methemoglobinemia, hemolysis, and hemoglobinuria, and there is a recommendation to check G6PD deficiency before use in high-risk patients.³⁰

TLS Treatment

Alkalinization. Alkalinization of urine is controversial in the management of TLS. Urine alkalinization increases uric acid solubility but causes hyperphosphatemia and decreases calcium phosphate solubility, which can then deposit in the kidney once cancer treatment starts. Of note, hyperphosphatemia is much more difficult to correct than high levels of uric acid, and there are no clinical trials proving the superiority of urine alkalinization over normal saline.

Normalization of electrolytes. Electrolyte abnormalities should be corrected to avoid arrhythmias and seizures. Phosphorus levels >6.5 mg/dl (2.1 mmol/L) should be managed by restricting phosphorus intake, and by the use of phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum, or aluminum hydroxide). Aluminum hydroxide should be avoided in patients with renal insufficiency. In severe cases of hyperphosphatemia, dialysis should be considered.

Symptomatic hypocalcemia should be treated with calcium gluconate if changes are present on the electrocardiography (ECG). Hypocalcemia in the presence of hyperphosphatemia should be treated only in patients with tetany or cardiac arrhythmias; otherwise, hypocalcemia should not be treated until hyperphosphatemia has been corrected.

In cases of hyperkalemia, patients should be placed on a cardiac monitor and stabilized with calcium gluconate; kayexalate should be administered to reduce total body potassium. Other interventions, such as intravenous insulin given with dextrose, sodium bicarbonate, and albuterol, have a temporary effect on hyperkalemia and can be used as adjunct treatments in patients with severe hyperkalemia (>7). Hemodialysis should be strongly considered in severe cases of hyperkalemia, particularly in patients with persistently elevated potassium levels despite other treatments.

Back to the Case

Our patient was started on IVFs with close monitoring of his urine output. He was considered intermediate risk for developing TLS. Allopurinol, renally dosed, was administered for two days prior to initiating treatment with rituximab plus chemotherapy. His chemistry panel was monitored daily and he did not develop any form of TLS.

Bottom Line

TLS is a common oncology emergency in patients with hematologic malignancies. Preventative measures include starting IVF prior to cancer treatment, and administering allopurinol and/or rasburicase to patients at risk of developing TLS. Treatment should include normalizing electrolytes to avoid arrhythmias and seizures.

Dr. Akwe is assistant professor of medicine at the Emory University School of Medicine and a clinical instructor of medicine at the Morehouse School of Medicine, both in Atlanta. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory. Both work as hospitalists at the Atlanta VA Medical Center.

References

1. Abu-Alfa AK, Younes A. Tumor lysis syndrome and acute kidney injury: evaluation, prevention, and management. Am J Kidney Dis. 2010;55:Suppl 3:S1-S13.
2. Cairo MS, Coiffier B, Reiter A, Younes A. Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus. Br J Haematol. 2010;149:578-586.
3. Gertz MA. Managing tumor lysis syndrome in 2010. Leuk Lymphoma. 2010;51:179-180.
4. Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364:1844.
5. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127:3.
6. Wössmann W, Schrappe M, Meyer U, et al. Incidence of tumor lysis syndrome in children with advanced stage Burkitt’s lymphoma/leukemia before and after introduction of prophylactic use of urate oxidase. Ann Hematol. 2003;82:160.
7. Hussain K, Mazza JJ, Clouse LH. Tumor lysis syndrome (TLS) following fludarabine therapy Gemici C. Tumor lysis syndrome in solid tumors. J Clin Oncol. 2009;27:2738-2739
8. Rostom AY, El-Hussainy G, Kandil A, Allam A. Tumor lysis syndrome following hemi-body irradiation for metastatic breast cancer. Ann Oncol. 2000;11:1349.
9. Drakos P, Bar-Ziv J, Catane R. Tumor lysis syndrome in nonhematologic malignancies. Report of a case and review of the literature. Am J Clin Oncol. 1994;17:502.
10. Baeksgaard L, Sørensen JB. Acute tumor lysis syndrome in solid tumors—a case report and review of the literature. Cancer Chemother Pharmacol. 2003;51:187.
11. Kalemkerian GP, Darwish B, Varterasian ML. Tumor lysis syndrome in small cell carcinoma and other solid tumors. Am J Med. 1997;103:363.
12. Noh GY, Choe DH, Kim CH, Lee JC. Fatal tumor lysis syndrome during radiotherapy for non-small-cell lung cancer. J Clin Oncol. 2008;26:6005-6006.
13. Pentheroudakis G, O’Neill VJ, Vasey P, Kaye SB. Spontaneous acute tumour lysis syndrome in patients with metastatic germ cell tumours. Report of two cases. Support Care Cancer. 2001;9:554.
14. Joshita S, Yoshizawa K, Sano K, et al., A patient with advanced hepatocellular carcinoma treated with sorafenib tosylate showed massive tumor lysis with avoidance of tumor lysis syndrome. Intern Med. 2010;49:991-994.
15. Huang WS, Yang CH. Sorafenib-induced tumor lysis syndrome in an advanced hepatocellular carcinoma patient. World J Gastroenterol. 2009;15:4464-4466.
16. Bilgrami SF, Fallon BG. Tumor lysis syndrome after combination chemotherapy for ovarian cancer. Med Pediatr Oncol. 1993;21:521.
17. Chan JK, Lin SS, McMeekin DS, Berman ML. Patients with malignancy requiring urgent therapy: CASE 3. Tumor lysis syndrome associated with chemotherapy in ovarian cancer. J Clin Oncol. 2005;23:6794.
18. Godoy H, Kesterson JP, Lele S. Tumor lysis syndrome associated with carboplatin and paclitaxel in a woman with recurrent endometrial cancer. Int J Gynaecol Obstet. 2010;109:254.
19. Shamseddine AI, Khalil AM, Wehbeh MH. Acute tumor lysis syndrome with squamous cell carcinoma of the vulva. Gynecol Oncol 1993;51:258
20. Pinder EM, Atwal GS, Ayantunde AA, et al. Tumour lysis syndrome occurring in a patient with metastatic gastrointestinal stromal tumour treated with Glivec (imatinib mesylate, Gleevec, STI571). Sarcoma. 2007;2007:82012.
21. Krishnan G, D’Silva K, Al-Janadi A. Cetuximab-related tumor lysis syndrome in metastatic colon carcinoma. J Clin Oncol. 2008;26:2406-2408.
22. Oztop I, Demirkan B, Yaren A, et al. Rapid tumor lysis syndrome in a patient with metastatic colon cancer as a complication of treatment with 5-fluorouracil/leucoverin and irinotecan. Tumori. 2004;90:514.
23. Lin CJ, Lim KH, Cheng YC, et al. Tumor lysis syndrome after treatment with gemcitabine for metastatic transitional cell carcinoma. Med Oncol. 2007;24:455.
24. Malik IA, Abubakar S, Alam F, Khan A. Dexamethasone-induced tumor lysis syndrome in high-grade non-Hodgkin’s lymphoma. South Med J. 1994;87:409.
25. Jabr FI. Acute tumor lysis syndrome induced by rituximab in diffuse large B-cell lymphoma. Int J Hematol. 2005;82:312.
26. Sezer O, Vesole DH, Singhal S, et al. Bortezomib-induced tumor lysis syndrome in multiple myeloma. Clin Lymphoma Myeloma. 2006;7:233.
27. Jensen M, Winkler U, Manzke O, et al. Rapid tumor lysis in a patient with B-cell chronic lymphocytic leukemia and lymphocytosis treated with an anti-CD20 monoclonal antibody (IDEC-C2B8, rituximab). Ann Hematol. 1998;77:89.
28. Linck D, Basara N, Tran V, et al. Peracute onset of severe tumor lysis syndrome immediately after 4 Gy fractionated TBI as part of reduced intensity preparative regimen in a patient with T-ALL with high tumor burden. Bone Marrow Transplant. 2003;31:935.
29. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008;26(16):2767-2778. [Erratum, J Clin Oncol. 2010;28:708.]
30. Cheuk DK, Chiang AK, Chan GC, Ha SY. Urate oxidase for the prevention and treatment of tumor lysis syndrome in children with cancer. Cochrane Database Syst Rev. 2010;(6):CD006945.
31. Cortes J, Moore JO, Maziarz RT, et al. Control of plasma uric acid in adults at risk for tumor Lysis syndrome: efficacy and safety of rasburicase alone and rasburicase followed by allopurinol compared with allopurinol alone—results of a multicenter phase III study. J Clin Oncol. 2010;28:4207.

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

(Editor's note: Updated July 12, 2013.)

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

(Editor's note: Updated July 12, 2013.)

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

(Editor's note: Updated July 12, 2013.)

Estimated number of first-year medical school enrollees in 2017, a 30% increase from 2002, according to the Association of American Medical Colleges.5 Sixty-two percent of this growth will take place at the 125 medical schools that have been accredited for a decade or more. Forty percent of surveyed medical-school deans expressed “major concerns” about enrollment growth outpacing the growth in residency-training positions for the graduates of medical schools.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

Estimated number of first-year medical school enrollees in 2017, a 30% increase from 2002, according to the Association of American Medical Colleges.5 Sixty-two percent of this growth will take place at the 125 medical schools that have been accredited for a decade or more. Forty percent of surveyed medical-school deans expressed “major concerns” about enrollment growth outpacing the growth in residency-training positions for the graduates of medical schools.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

Estimated number of first-year medical school enrollees in 2017, a 30% increase from 2002, according to the Association of American Medical Colleges.5 Sixty-two percent of this growth will take place at the 125 medical schools that have been accredited for a decade or more. Forty percent of surveyed medical-school deans expressed “major concerns” about enrollment growth outpacing the growth in residency-training positions for the graduates of medical schools.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

New CDC research published in the June issue of Infection Control and Hospital Epidemiology estimates that as many as 200,000 central-line-associated bloodstream infections (CLABSIs) in ICUs nationally have been prevented since 1990.³ The report indicates much of the success is due to U.S. hospitals adopting successful prevention strategies, namely the dissemination of guideline-supported central-line insertion and maintenance best practices, infection-control treatment bundles, and widespread availability of alcohol-based hand rubs.

Between 462,000 and 636,000 CLABSIs occurred in non-neonatal ICU patients from 1990-2010, CDC estimates, about 104,000 to 198,000 less CLABSIs than would have occurred if rates had remained the same as they were in 1990.

“These findings suggest that technical innovations and dissemination of evidence-based CLABSI prevention practices have likely been effective on a national scale,” Matthew Wise, PhD, lead author of the study, said in a statement.

At the same time, a CLABSI-reduction intervention in a hospital in Hawaii found that while the costs of care were much higher for patients who developed a CLABSI, reimbursement and the hospital’s margin also were higher (margin of $54,906 vs. $6,506).⁴ The authors conclude that current reimbursement practices offer a perverse incentive for hospitals to have more line infections, “while an optimal reimbursement system would reward them for prevention rather than treating illness.”

Lead author Eugene Hsu, MD, MBA, of Johns Hopkins University School of Medicine said in an email that the study demonstrates how a quality initiative led by providers and funded by a major commercial insurer can save both lives and money. “Hospitalists, like all healthcare providers, must be aware of the distorted financial incentives that may affect how they provide care to patients,” Dr. Hsu said.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

New CDC research published in the June issue of Infection Control and Hospital Epidemiology estimates that as many as 200,000 central-line-associated bloodstream infections (CLABSIs) in ICUs nationally have been prevented since 1990.³ The report indicates much of the success is due to U.S. hospitals adopting successful prevention strategies, namely the dissemination of guideline-supported central-line insertion and maintenance best practices, infection-control treatment bundles, and widespread availability of alcohol-based hand rubs.

Between 462,000 and 636,000 CLABSIs occurred in non-neonatal ICU patients from 1990-2010, CDC estimates, about 104,000 to 198,000 less CLABSIs than would have occurred if rates had remained the same as they were in 1990.

“These findings suggest that technical innovations and dissemination of evidence-based CLABSI prevention practices have likely been effective on a national scale,” Matthew Wise, PhD, lead author of the study, said in a statement.

At the same time, a CLABSI-reduction intervention in a hospital in Hawaii found that while the costs of care were much higher for patients who developed a CLABSI, reimbursement and the hospital’s margin also were higher (margin of $54,906 vs. $6,506).⁴ The authors conclude that current reimbursement practices offer a perverse incentive for hospitals to have more line infections, “while an optimal reimbursement system would reward them for prevention rather than treating illness.”

Lead author Eugene Hsu, MD, MBA, of Johns Hopkins University School of Medicine said in an email that the study demonstrates how a quality initiative led by providers and funded by a major commercial insurer can save both lives and money. “Hospitalists, like all healthcare providers, must be aware of the distorted financial incentives that may affect how they provide care to patients,” Dr. Hsu said.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

New CDC research published in the June issue of Infection Control and Hospital Epidemiology estimates that as many as 200,000 central-line-associated bloodstream infections (CLABSIs) in ICUs nationally have been prevented since 1990.³ The report indicates much of the success is due to U.S. hospitals adopting successful prevention strategies, namely the dissemination of guideline-supported central-line insertion and maintenance best practices, infection-control treatment bundles, and widespread availability of alcohol-based hand rubs.

Between 462,000 and 636,000 CLABSIs occurred in non-neonatal ICU patients from 1990-2010, CDC estimates, about 104,000 to 198,000 less CLABSIs than would have occurred if rates had remained the same as they were in 1990.

“These findings suggest that technical innovations and dissemination of evidence-based CLABSI prevention practices have likely been effective on a national scale,” Matthew Wise, PhD, lead author of the study, said in a statement.

At the same time, a CLABSI-reduction intervention in a hospital in Hawaii found that while the costs of care were much higher for patients who developed a CLABSI, reimbursement and the hospital’s margin also were higher (margin of $54,906 vs. $6,506).⁴ The authors conclude that current reimbursement practices offer a perverse incentive for hospitals to have more line infections, “while an optimal reimbursement system would reward them for prevention rather than treating illness.”

Lead author Eugene Hsu, MD, MBA, of Johns Hopkins University School of Medicine said in an email that the study demonstrates how a quality initiative led by providers and funded by a major commercial insurer can save both lives and money. “Hospitalists, like all healthcare providers, must be aware of the distorted financial incentives that may affect how they provide care to patients,” Dr. Hsu said.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

One in 20 hospitalized patients picks up an infection in the hospital, and a recent article by the Associated Press describes the emergence of new technologies to fight antibiotic-resistant superbugs: “They sweep. They swab. They sterilize. And still the germs persist.”¹

Hospitals across the country are testing new approaches to stop the spread of superbugs, which are tied to an estimated 100,000 deaths per year, according to the CDC. New approaches include robotlike machines that emit ultraviolet light or hydrogen-peroxide vapors, germ-resistant copper bed rails and call buttons, antimicrobial linens and wall paint, and hydrogel post-surgical dressings infused with silver ions that have antimicrobial properties.

Research firm Frost & Sullivan estimates that the market for bug-killing products and technologies will grow to $80 million from $30 million in the next three years. And yet evidence of positive outcomes from them continues to be debated.

“In short, escalating antimicrobial-resistance issues have us facing the prospect of untreatable bacterial pathogens, particularly involving gram-negative organisms,” James Pile, MD, FACP, SFHM, a hospital medicine and infectious diseases physician at Cleveland Clinic, wrote in an email. “In fact, many of our hospitals already deal with a limited number of infections caused by bacteria we have no clearly effective antibiotics against; the issue is only going to get worse.”

As an example, the CDC recently issued a warning about carbapenum-resistant Enterobacteriaceae (CRE), which has a 40% mortality rate and last year was reported in 4.6% of U.S. hospitals.² CDC recommends that hospitals use more of the existing prevention measures against CRE, including active-case detection and segregation of patients and the staff who care for them. Dr. Pile says health facilities need to do a better job of preventing infections involving multi-drug-resistant pathogens, but in the meantime, “proven technologies such as proper hand hygiene and antimicrobial stewardship are more important than ever.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

One in 20 hospitalized patients picks up an infection in the hospital, and a recent article by the Associated Press describes the emergence of new technologies to fight antibiotic-resistant superbugs: “They sweep. They swab. They sterilize. And still the germs persist.”¹

Hospitals across the country are testing new approaches to stop the spread of superbugs, which are tied to an estimated 100,000 deaths per year, according to the CDC. New approaches include robotlike machines that emit ultraviolet light or hydrogen-peroxide vapors, germ-resistant copper bed rails and call buttons, antimicrobial linens and wall paint, and hydrogel post-surgical dressings infused with silver ions that have antimicrobial properties.

Research firm Frost & Sullivan estimates that the market for bug-killing products and technologies will grow to $80 million from $30 million in the next three years. And yet evidence of positive outcomes from them continues to be debated.

“In short, escalating antimicrobial-resistance issues have us facing the prospect of untreatable bacterial pathogens, particularly involving gram-negative organisms,” James Pile, MD, FACP, SFHM, a hospital medicine and infectious diseases physician at Cleveland Clinic, wrote in an email. “In fact, many of our hospitals already deal with a limited number of infections caused by bacteria we have no clearly effective antibiotics against; the issue is only going to get worse.”

As an example, the CDC recently issued a warning about carbapenum-resistant Enterobacteriaceae (CRE), which has a 40% mortality rate and last year was reported in 4.6% of U.S. hospitals.² CDC recommends that hospitals use more of the existing prevention measures against CRE, including active-case detection and segregation of patients and the staff who care for them. Dr. Pile says health facilities need to do a better job of preventing infections involving multi-drug-resistant pathogens, but in the meantime, “proven technologies such as proper hand hygiene and antimicrobial stewardship are more important than ever.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

One in 20 hospitalized patients picks up an infection in the hospital, and a recent article by the Associated Press describes the emergence of new technologies to fight antibiotic-resistant superbugs: “They sweep. They swab. They sterilize. And still the germs persist.”¹

Hospitals across the country are testing new approaches to stop the spread of superbugs, which are tied to an estimated 100,000 deaths per year, according to the CDC. New approaches include robotlike machines that emit ultraviolet light or hydrogen-peroxide vapors, germ-resistant copper bed rails and call buttons, antimicrobial linens and wall paint, and hydrogel post-surgical dressings infused with silver ions that have antimicrobial properties.

Research firm Frost & Sullivan estimates that the market for bug-killing products and technologies will grow to $80 million from $30 million in the next three years. And yet evidence of positive outcomes from them continues to be debated.

“In short, escalating antimicrobial-resistance issues have us facing the prospect of untreatable bacterial pathogens, particularly involving gram-negative organisms,” James Pile, MD, FACP, SFHM, a hospital medicine and infectious diseases physician at Cleveland Clinic, wrote in an email. “In fact, many of our hospitals already deal with a limited number of infections caused by bacteria we have no clearly effective antibiotics against; the issue is only going to get worse.”

As an example, the CDC recently issued a warning about carbapenum-resistant Enterobacteriaceae (CRE), which has a 40% mortality rate and last year was reported in 4.6% of U.S. hospitals.² CDC recommends that hospitals use more of the existing prevention measures against CRE, including active-case detection and segregation of patients and the staff who care for them. Dr. Pile says health facilities need to do a better job of preventing infections involving multi-drug-resistant pathogens, but in the meantime, “proven technologies such as proper hand hygiene and antimicrobial stewardship are more important than ever.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn